HomeMy Public PortalAbout6466 LOMA AVE_Sewer__ 76A64 10.62 APPLICATION FOR PERMIT
78A 842D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / �D
JOHN A. LAMBIE, County Engineer ADDRESS ltd
WILLIAM A. JENSEN, Sup't of Building
LOCALITY l '(� ('`&
NEAREST /"� g U )A
FOR APPLICANT TO FILL IN CRQSr ST.
LEGALn� /{
DESCRIPTION LOT NO. OWNER `,� Cr 0 ti
MAIL
BLOCK TRACT ADDRESS SIF Q �u
NO. OF BLDGS. C
SIZE OF LOT NOW ON LOT -CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROC 5 ED BY
BK PG l
CONTRALTO
'/iso' 1W Sv• C r C. Q
ADDRESS ._ Winz ` , •uG ve CONNECTION DATA
_ STATION DEPTH
CITY ao (( C4dq-ITEL. NO. 4r r.
�!� 7 STATE MANHOLE REFERENCE 0 PPER
REGISTRATION NO. V (i ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ENGTH FROM O
HOUSE SEWER CONNECTING TO Y: CURB P.
, M.L.TO P.L. U
PUBLIC SEWER @ $5.00 ) ,
ems.. P.C.NO. �
SEPTIC TANK,SEEPAGE PIT OR O
PITS AND/OR DRAINFIELD @ S10.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 Uj
CONN ECTADOITIONAL BLDG.OR AFFIDAVIT I AIVEN I EASEMENT RECORD.INSTR. DATE d
WORK TO HOUSE SEWER @ $3.00 Z
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYW EL L,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WID ING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHME
PERMIT NO.
INDUSTRIAL
WASTE APPROV
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 0 0 CONNECTION CHARGE FEE
I HAVE.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. _ APPROVALS DATE INSPECT.O S SIGNATURE
SIGNED THIS AY F / 19 / v"
OWNER OR __�� /^CyEr,// _ NEW HOUSE SEWER ' �4"d� ~
OWNERS AGENTT_r.c-��) G(_�/�l�( ~� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR .-
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I�1 M THE LEGAL OWNER OF, ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DESCR ED RESIDENTIAL ROPE RTY. ABANDON HOUSE SEWER
/
SIGNATURE ElOF PERMITTEE ✓ rL �,,.�/ BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
- CK. M.O. CASH
5 8 8 7:0' FEB 2 5 1 0 D '7,0 CSN
%dam
4,72
76A642L - APPLICATION FOR PERMIT
76A64
COUNTY OF L05 ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
[LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. Aby 6_
LEGAL /
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK " RACT ADDRESS
NO. OF BLDGS. / (� TEL. NO.
SIZE OF LOT NOW ON LOT CITU
USE OF
BUILDINGS 9' DISTRICT N0. GROUP DHAP /�77 PROCESSED BY
BK PG
CONTRACTOR Al
ADDRESS �j CONNECTION DATA
CITY `J )_ TEL. NO. 7-e _ STATION •� / DEPTH ,
STATE LIC UPPER
LICENSE NO: / CLASS MANHOLE REFERENCE ,
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM 29('
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P,L. 7�
PUBLIC SEWER @ 1'
SEPTIC TANK.SEEPAGE PIT OR - P.C.NO. a
CO. IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM @ lx
CONNECT ADDITIONAL BLDG.OR 0 /1 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO.'� - DATE O
WORK TO HOUSE SEWER @ 'L/
OVERFLOW SEEPAGE PIT.DRAINFIELD '� H
EXTN..CESSPOOL.DRYWELL.MANHOLE @ YY Lu
V
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Lir Q.
SEWER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT elh
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S J UCT
AUTHORIZATION TOTAL FEE /)!1 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. I APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF T'9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL �,p+
ADDRESS BUILDING OR WORK CF
SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH15 APPLICATION AND/OR DRAINFIELD -
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING ,
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF .AND INTEND T DISCONNECT PLUG AND
RESIDE IN. THE A]2ED R 5 TI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE �. BACKFILL SEPTIC TANKS ClOF PERMrrTEE ❑
SEEP.PITS) ❑ CESSPOOLS
DATION
CK. td.O. CASH
4 7 .9tAPR 111 U D 6,0 0A3