HomeMy Public PortalAbout4924 HALLOWELL AVE_Sewer__ 4
70AG420
cEape a-46 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND'SAFETY DIVISION 6uILDING
ADDRESS
]rOHN A. LAMHIE, County En jar CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST '
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL C t t
DESCRIPTION LOT N0. ...,r OWNER "
BLOCK TRACT MAIL
ADDRESS
{- N0.OF BLDGS. ,
SIZE OF LO j NOW ON LOT CITY TEL.'NO. "
USE OF
BUILDINGS DISTRICT N0: GROUP MAP P 0 ESSED Y '
BK. PG
CONTRACTOR la� 1
�- �f.{�
ADDRESS w, ,� v Z;Z O «' CONNECTION DATA
CITY �/'/,JEEL.NO. STATION DEPTH
REGISTRATION NOZ�� 'f fs Y Z- •V A TE MANHOLE REFERENCE UPPER
COUNTY -LOWER
NO. I DESCRIPTION OF WORK, FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER, @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR' - Yl. CURB P.L. M.L.TO P.L.
'PITS AND/OR DRAINFIELD, @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO'• - P.C.NO., -
PRIVATE DISPOSAL SYSTEM @-$1.00 CO.IMP. NO. ;'JOB NO.
CONNECWORK TOTHOUSEISEWER DDITONAL BLDG.OR @ S1 00 TRUNK PERMIT NO. ROAD PERMIT NO.
J ALTER, HOUSE STATE ENCROACHMENT
SEWER'tiR�BF6A6r,*L SYSTEM @ $1.00 �"d PERMIT NO.
INDUSTRIAL•
WASTE APPROVAL
CHARGES '
OVMER'S PERMIT $ 2 DO - CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 3 REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE NAMED CONr
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTItNG DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL _
OWNERS AGENT BUILDING OR-WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)"
AND/OR DRAINFIELD
1 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 SEWERS. - SEWAGE DISPOSAL SYSTEM $ S'
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT Ir AM THE LEGAL'OWNER OF THE ABOVE
_DESCRIBED RESIDENT A OPEI�Y. - BACKFILL SEPTIC TANKS ❑ -
SIGNATURE. _ SEEP. PIT(S) ❑ CESSPOOLS -
OF PERMITTE - -OF VALIDATIO ROBERT A. WOOD
OK X.p, CASH 'SUPERVISING MECHANICAL ENGINEER