HomeMy Public PortalAbout4923 HALLOWELL AVE_Sewer__ `E'BDB 1i-68
7eA eazo APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �� �
JOHN A. LAMBIE. COUNTY ENGINEER AODRE48
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CR068 BT
aAL
DESCRIPTION LOT NO. OWNER
MAIL i
BLOCK TRACT ADDRESS Sires
[[QQ
-7 o NO. OF BIL
SIZE OF LOT8 ( {,/ NOW ON LOT CITY TEL. NO.
USE OF \"��� DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS Y
BK jjPa
CONTRACTOR
ADDRESS S N, P CONNECTION DATA
CITY TEL NO�2-3 STATION DEPTH
STATE /� LIC 2 UPPER
LICENSE NO 33 L/ CLASS {�� MANHOLE REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO �f-a Y CURB P L. ML TO P L.
PUBLIC SEWER a ,aj6•�lT
SEPTIC TANK SEEPAGE PIT OR P C.NO.
PITS AND/OR DRAINFIELD $1000 CO.IMP NO. JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIY[R [AS EM[KT RECORD INSTR NO DATE 0
U
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT DRAINFIELD
0
EXTN CESSPOO MANHOLE $500 HWY OR STWIDENING
ALTER REPAIR ORR ABANDON
NDON HOUSE . ()
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERmrr $ CHARGES
AUTHORIZATION rTOTAL FEE OO CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH E HEREIN NAMED CON.- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DES
C ED E) STING DWELLING
TO THE PUBLIC SE APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS 'OF
OWNER OR
NEW HOUSE SEWER
OWNERS AGENT [CONNECT ADDITIONAL
ILDING OR WORK
ADDRESft
S EPT IC'TANK,SEEP,PIT(S)
1 HEREB A NOWLEDGE THAT I HAVE READ THIS APPLICA ION q; D- R DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 1
WITH ALL COUNTY
EWORDINANCES AND STATE LAS REGULATING Cl
PLUMBING AND SEWERS I CESSPOOL DRYWELL '
I HEREBY CERTIFY THAT I A ERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY L ANGL COUNTY AND STATE OF SEWAGE D ISPOSAL SYSTEM
CALIFORNIA OR T AT I A T E LEGAL OW R , AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, T RI ED RE ID TIA PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MTTTE SEEP,PIT(S) ❑ CESSPOOLS ❑
V ON JACK R. ALLEN
J1 "
M. CASH SUPERVISING MECHANICAL ENGINEER
LAC62:4 3 ?N SEPI l 0 D 6.0 0-