HomeMy Public PortalAbout4935 HALLOWELL AVE_Sewer__ 76A 642D - CE808 - 9/73 APPLICA ION FOR PER IT , �.
' COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS '2 Via
LOCALITY
NEAREST
FOR APPLICA TO FILL IN .CROSS ST
LEGAL
DESCRIPTION LOT NO. OWNER
_ MAIL
BLOCK TRACT 0 � ADDRESS
NO. OF SLOGS J
SIZE OF LOT NOW ON LOT CITY TEL. NO. (j
USE OF DISTRICT NO GROUP MAP ESSED BY_ _
BUILDINGS A BK P3
60NTRACTOg Z7
ADDRESS � V• CONNECTION DAT
CITY TEL NOSTATION , 2-- DEPTH '
STAT LI MANHOLE REFERE CE �( UPPER
LICENSE NO. CLASS (J LOiilll�"
NO DESCRIPTI N OF WOFfK FEE TYPE OF CONNECTION_ _LENGTH FROM
HOUSE SEWER CONNECTING TOY CURB M.L TOP L.
PUBLIC SEWER -$7.00
P.0 NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® SIO GO CO.IMP. NO. 132- JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT,NO.
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVES I EASEMENT RECORD.INSTR NO DATE
WORK TO HOUSE SEWER $300 d
OVERFLOW SEEPAGE PIT.DRAINFIELD C )
E%TN.CESSPOO L.DRYWELL. iS.00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT CD
MANHOLEPERMIT NO. U
$7.00 INDUSTRIAL a
WASTE APPROVAL N
CHARGES
OWNERS PERMIT
CONNECTION CHARGE FEE --
AUTHORIZATION I TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED LISTING DWELLING
TO THE PUBLIC SEWER _ APPROVALS DATE INSPECTOR'S SIGNATURE ,
SIGNED THIS �OF 19_ 7-4-
OWNER OR NEW HOUSE SEWER C _
OWNERS AGENT - -
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(5) - •
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑- DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY RE ISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LO NGLES COU Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCRN IA AT I AM THE GAL O NE O�A INTEND TINTEND T DISCONNECT PLUG AND
RESIDE IN H SGR lRES ABANDON HOUSE SEWER
SIG BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION CK. M.0. CASH
9 77-NIAR' 3 1 o: l 5.0 0
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