HomeMy Public PortalAbout4836 HALLOWELL AVE_Sewer__ ��
CE808 12-68
76A 6420 APPLICATION FOR PEReM_ T
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROBS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
/ ! MAIL
BLOCK TRACT ./3C0 � ADDRESS
NO. OF BLDGS,
SIZE OF LOT �V NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
PG
CONTRACT R �K
ADDRESS CONNECTION DATA
CITY I L. NO i1 STATION DEPTH
DEPTH f
STATE LIC V MANHOLE REFERENCE J�+I l �[J. (� UPPER
LIC"SE NO: CLASS 7 ( LOWER
NO. DESC IPTION OF WOR FEE s TYPE OF TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 591.11
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD (� $IO.Op CO.IMP. NO. JO9 NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER @ S3.00
O.
OVERFLOW SEEPAGE PIT,DRAINF)ELD Q
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $5.00 16-
ALTER.
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING C.)
W
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
CL
_ PERMIT NO, C/)�
INDUSTRIAL
WASTE APPROVAL
CHARGES
�'OWNERIS PERMIT � $ z o0
AUTHORIZATION ION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A .CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TN
RACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLIG
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
f
SIGNED THIS AY
OWNER OR NEW HOUSE SEWER
OWNERS A ENT CONNECT ADDITIONAL r
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT, HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/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 DI.SCON NECT PLUG AND
RESIDE IN, THE VE DE RIBED RESIDENT L PROPS Y. ABANDON HOUSE SEWER
51GNRE
0E ATU
PER. E BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
,,-VALIDATION JACK R. ALLEN
�
M.O. CASH SUPERVISING MECHANICAL ENGINEER
K.
4.A�'� 7 1 5 6R OCT.14 1 0 0 7.00-