HomeMy Public PortalAbout4826 HALLOWELL AVE_Sewer__ CE80842D 3-
78A662 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING IV
JOHN A. LAMBIE, County Engineer AODREss
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL / •
DESCRIPTION LOT NO ,S OWNER
�1 MAIL
BLOCK TRACT T�^ ADDRESS
vj-
4!` NO. OF BLDGS. .� {�
SIZE OF LOT NOW ON LOT CITY EL NO. p...
USE OF DISTRICT NO. GROUP MAP ZZ
BY
BUILDINGS
V w BK PG//
CO NT RAC t lJ O l� .Jl�i �•�'
ADDRESS CONNECTION DATA
CITY NO STATION DEPTH
STATE P ER
REGISTRATION NO LJ COUNTY MANHO EFER NCE ER
NO DESCRIPTION OF WORK FEE TYPE OF O TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL MIL TO P L. ¢
PUBLIC SEWER @ $5 00 P C.NO. O
SEPTIC TANK,SEEPAGE PIT OR JOB NO
PITS AND/OR DRAINFIELD @ 31000 CO.IMP NO
HOUSE SEWER CONNECTING'TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEx ENT RECORD IN5TR.NO. DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER 05 DISPOSAL SYSTEM @ $3 09 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 5 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q-Z�
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER _ APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER ? A�
OWNERS AGENT_ ny'� K, w,
CONNECT ADDITIONAL A� j ,,,,�//� F s=
ADDRESS BUILDING OR WORK j� .S6y-� k iC7q .y.
SEPTIC TANK,SEEP,PITS) a
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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 TO DISCONNECT PLUG AND
RESIDE IN, THE ABO E DESRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM TEE SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK M O cASH SUPERVISING MECHANICAL ENGINEER
6 8 6 3'� tJIIU 3 1 0 D S.0 0 0
' i