HomeMy Public PortalAbout4805 HALLOWELL AVE_Sewer__ 6550 INSERTS
,CEB08APO0 LI A C I®C�,I FOR U R IM IT -
7eAe42D COUNTY OF LOS ANGELES SEWER-SEWAGE, DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION FIDDRESS'
� �� Y
� Z� 'IF.,JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building FOR APPLICANT TO FELL IN
LEGAL OWNER. -
DESCRIPTION LOT NO. _
BLOCK TRACTO MAIL
'ADDRESS
NO OF BLS.
SIZE OF LOT • NOW ON L T -� CITY TEL NO
USE OF DISTRICT NO. GROIN MAP PROCESS BY
BUILDINGS /�
/` BK PG
CONTRALTO �� �� 0' rVl
ADDRESS CO CTION DATA '
CII=:S-.S�� TEL � 72 STATION DEPTH
STATE - MANHOLE REFERENCE UPPER
REGISTRATION NO. Z�' COUNTY LOWER
NO. DESCRIPTION OF WORK FEE a
V V
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TY0E OF CONCiION- LENGTH,FROM -
PITS AND/OR DRAINFIELDSEPTIC TANK,SEEPAGE T OR @ $3 00 Y. CUR P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD '
EXTN CESSPOOL DRY WELL
@ $2 00 -
HOUSE SEWER CONNECTING TO - P.C.NO. -
PRIVATE DISPOSAL SYSTEM @ $1 00
CO/14.-NO JOB-NO.
CONNECT ADDITIONAL BLDG OR - TRUNK PERMIT NO.. ROAD PERMIT NO, Q
WORK TO HOUSE SEWER 00 V ,
SEEOR REPAIR
R ABANDON SSTEM HOUSE @ $1 00 'STATE ENCROACHMENT
WR • 04
'PERMIT NO O
INDUSTRIAL E)
_ WASTE APPROVAL W
Ck
CHARGES Ul
OWNERS PERMIT' $ 21 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREI AMED CON; _
TRACTOR TO CONNECT THE ABOVE SCRIBED EXIST/NG DWELLING APPROVALS_ DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S ER. - -
SIGNED THIS F _19= NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK -
ADORESS SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
I.HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION,-
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO C PLY CESSPOOL ❑ .DRYWELL ❑ '
WITH ALL UN INANCES.AND STATE LAWS REGUL ING - ALTER„REPAIR;SEWER OR - - ,-- -- --
PLUMBING WERS SEWAGE DISPOSAL SYSTEM
I HER CERTIFY AT I AM PROPERLY REGIST ED AND/OR DISCONNECT PLUG AND '
LICEN D AS REQUI BY LOS ANGE ,COUNTY ND TE,OF -ABANDON HOUSE SEWER - - " '• '- - '
CALIF R D, OR T f AM THE
OWNER F MOVE '
DES I D,REST A PROPERTY. BACKFILL SEPTIC TANKS.❑'
SIG T / SEEP. PIT(S) ❑ CESSPOOLS ❑
OF I E
®r AMATIO ROBERT A. WOOD
m o cASR SUPERVISING MECHANICAL ENGINEER
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