HomeMy Public PortalAbout4911 HALLOWELL AVE_Sewer__ CEBOB 12-66 APPLICATION FOR PERMI
76A 642D 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 FIIAL IN CRD 55 ST
LEGAL p
DESCRIPTION LOT NO. �� OWNER
�dCK ��d s ` C/� d ADDRESS
¢ �/ NO. OF BLDG8. - J
SIZE/OF LOT P /�1 NOW ON LOT CITY NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
1
ADDRESS ' CONNECTION.D TA
► STATIONUPPER,_5— DEPTH
CITY L NO /y
STATE LIC MANHOLE REFERENCE yl�'�
LICENSE NO. CLA BS '10 /
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH ROM
HOUSE SEWER CONNECTING TO V Y CURB P.L M.L.TO .L.
PUBLIC SEWER $3.00 (�(J
SEPTIC TANK,SEEPAGE PIT OR P.0 NO. I
PITS AND/OR DRAINFIELD 110.00- CO IMP NO. JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $300 TRUNK PERMIT NO ROAD PERMIT NO. CL
0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVE■ EASEMENT RECORD.INSTR NO. DATE ()
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.CESSPOOL DRYWELL MANHOLE Q $5 00
HWY.OR ST WIDENING ~
ALTER,REPAIR OR ABANDON HOUSE W
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT CL
PERMIT NO, N
Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER 71 APPROVALS D E INS TOR'S 1 ATURE
SIGNED THIS. DAY OF 19�J^
�
OWNER OR ���/J�' NEW HOUSE SEWER
OWNERS AGENT_!
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
(1
SEPTIC TANK,SEEP,PIT(S)
I HEREBY A KNOWLEDGE THAT 1 HAV READ THI APPLICATION A-VD/OR DRAINFIELD
AND STATE THAT THE ABOVE IS Co
T 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 ANO/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT P G AN
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PR ER Y. ABANDON HOU SEW
L
SIGNATURE
OF PERMITTEE BACKFILLS /
SEEP.PIT P L
VALIDA CJACK ALLEN
CK M 0 ASH
S PERVISING MECHANICAL ENGINEER
� '