HomeMy Public PortalAbout4827 HALLOWELL AVE_Sewer__ I
76A642 D-61 APPLICATION FOR PERMIT �S
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DIVOSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fC
I60 7
LDING /
JOHN A, LAMBIE. County En aeer DRESS
WILLIAM A. JENSEN. Supt of Building CALITY
AREST
FOR APPLICANT TO FUl IN oss ST. f
LEGAL OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT s ADDRESS L
NO.OF BLQGS. '
SIZE OF LOT NOW ON LOT CITY TEL.-NO.
USE OFDI m DISTRICT NO. GROUP MAP IESSED BY
BUILDINGS "C CiC� � .y/'JCONTRACT ,e a 5 /y i /"/ P.71 yJ 4
ADDRESS v v �f .CONNNECTION DATA . 'Oris
CITY TEL.N STATION DEPTH
• STATE MANHOLE REFERENCE 21 L UPPER,
REGISTRATION NO. COUNTY
No. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ .00 PE OF CONNECTION LENGTH FROM Q
SEPTIC TgNK,SEEPAGE PIT OR CURB. P.L. M.L.TO P.L. V
ITS AND/OR DRAINFIELD @ S .00
OVERFLOW SEEPAGE PIT,DRAINFIELD }
EXTN..CESSPOOL.DRYWELL S .00 d
HOUSE SEWER CONNECTING TO P.C.NO. 0
PRIVATE DISPOSAL SYSTEM @ S .00 CO.IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER S .00 O
FEWER OR DAISPOSAL SYSTEM HOUSE @ $ 00 STATE ENCROACHMENT `
PERMIT N0, t5j'
INDUSTRIAL d "'
WASTE APPROVAL h
CHARGES Z
OWIVER�S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS ATEI INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OR 9_ NEW HOUSE SEWER s. -
OWNER OR CONNECT ADDITIONAL /
OWNERS AGENT BUILDING OR WORK
ADDRESS 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 COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND S SEWAGE DISPOSAL SYSTE
1 HEREBY TIFY T AT 1 AM PROPERLY REGISTE D AND/OR DISCONNECT PLUG AND
LICENSED EOUIRE BY LOS ANGELES COUNTY A STATE OF ABANDON HOUSE SEWER
CAL•IFORNI R THA 1 AM THE LEGAL OWNER 0 THE ABOVE L SEPTIC TANKS ❑
SIGNATU
DESCRIBE ESIDE AL PROPERTY. BACKFISEEP.PLL S ❑ CESSPOOLS
El
OF PER
VALIDATIO ROBERT A. WOOD
CK. R.O. CASH SUPERVISING MECHANICAL ENGINEER
LA!";&0 9 5 3 APr, 12 1 0 0 7.0 0
i/