HomeMy Public PortalAbout8621 HALDEMAN ST_Sewer__ 24650, INSERTS'
`CEAPPLICATION FOR PERMIT.-
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78A642D 842D
COUNTY OF LOS ANGELES SEWER—$EWAq IsPQSAL
DEPARTMENT OF COUNTY ENGINEER • eu1LDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County Engineer,
WILLIAM A. JENSEN, Supt of Building LOCALITY .J I ' 5_
NEAREST '
FOR APPLICANT_,TO FILL IN CROSS ST.
LEGAL'
DESCRIPTION LOT N0. .OWNER
R. P39 BLOCK TRACT MAIL -�/ 'ADDRESS. Lt7NO OF-BLD #. IiSIZE OF L NOW ON LOTCITY - TEL NUSE0 DISTRICT NO. GROU MAP' BY
BUIL NGSLl BK
CONTRACT
ADDRESS CONNECTIO DATA
I STATION � DEPTH
CITY TEL NO. '
ATE MANHOLE REFERENCE
REGISTRATION N0. COUNTY -
N0. DESCRIPTION OF WOR FE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROl7
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. CJ -
PITS AND/OR DRAINFIELD @ $3.00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD "
EXTN CESSPOOL DRYWELL @ $2.00 -
HOUSE SEWER CONNECTING TO - P.C.N0. ,
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. •- ROAD PERMIT N0, Q
WORK TO HOUSE SEWER @ $1 00 • U -
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO. - -
_INDUSTRIAL -
WASTE APPROVAL - W _
CHARGES
OWNERS PERMIT' s 2 00 CONNECTION'CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNE THE ABOVE DESC IBED EXISTING DWELLING APPROVALS DATE INSPECTOR'SSIGNATURE-
TO THE- PUBLIC SEW
SIGNED THIS AY OF 19- NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE •THAT-I HAVE_READiTHIS APPLICATION
AND STATE THAT THE ABOV S CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ - `
WITH ALL 'COUNTY OR I NCES AND STATE LAWS REGULATING ALTER,REPAIR,'SEWER OR
PLUMBING AND SEWE SEWAGE DISPOSAL SYSTEM
I HEREBY'CERTI HAT I AM PROP Y REGIST ED AND/OR DISCONNECT PLUG AND -
LICENSED AS RE ED BY LOS ANGE OUNTY ND STATE OF ABANDON HOUSE SEWER "
CALIFORNIA 0 1 AM THE LE L W E THE ABOVE
DESCRIBED R L PROPERT BACKFILL SEPTIC TANKS ❑ -
SIGNATURE SEEP PIT(s) ❑ CESSPOOLS
NNW OF PERM TE
®p VALIDATIO ROBERT A. WOOD
CK. M.0: -CASH SUPERVISING MECHANICAL ENGINEER '