HomeMy Public PortalAbout4938 HALLOWELL AVE_Sewer__ 76A642D
`EaOB(REV 6,78. APPLICATIONtFOR PERMIT- ,, .
SEWER - SEWA,GE DISPOSAL
COUNTY OF,LOS ANGELES BUILDING'.''ND'SAFETY ''•
•FOR APPLICANT TO FILL IN DISTRICT NO', .GROUP n)`BK I MAP:•'SPG ;• i_^PROCE S D BY '
BUILDING •7�'��' �• IL, , - �w„�
ADDRESS ^J •� • _
CONNECTION DATA ' •-
LOCALITY '- � � '1
NEAREST - STATIO 1-•o EPTH j' D
/-
CROSS ST •z `1 ---•••��� •'�•� ,PPER
�/ y' /' ' MANHOLE REFERENC E�O �.V .7 —
�� {� OWER
OWNER,;2,
//CiG��y� ' TYPE OF TION' ; LENGTH FRO+MJ`- '• 4�
MAIL, - 'Y. GUR P L M L.TO P,L '
ADDRESS
CITY .L / TEL'NO�,•��O Z. �� GO IMP NO "JOB NO "
LEGAL TRUNK PERMIT NO, ROAD PERMIT NO
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER- EASEMENT I RECORD INSTR.NO DATE '
BLOCK ,TRACT �•y� ,
' NO.OF•BLDGS.
SIZE OF LOT NOW ON LOT _ HWY.OR ST.WIDENING
USE
BUILDINGS, STATE ENCROACHMENT
-
PERMIT NO
INDUSTRIAL
CONTRACTOR G C� // - WASTE APPROVAL -
' CHARGES
ADDRESS
CITY TEL NO
CONNECTION CHARGE FEE
�
STATE LIG. REIMBURSEMENT FEE ,
LICENSE NO. CLASS
NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TOPUBLIC -
- SEPTIC TANK. NEW HOUSE SEWER
SEEPAGE PIT OR I/��1 n✓ew'jP- �°.r� �-
+
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO - BUILDING OR WORK ,
PRIVATE DISPOSAL SYSTEM -
CONNECT ADDITIONAL BLDG.OR
SEPTIC TANK,SEEP.PIT(S) �p
WORKTO HOUSE SEWER - > AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL;MANHOLE CESSPOOL Q DRYWELL❑
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR '
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM'
-D(SCONNECT'PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ r - - - - ,,,
OWNER'S
Permit SEEP:PITS)El CESSPOOLS El
AUTHORIZATION " TOTAL FEE `" • 'VALIDATIONS--'"
L*Z�
I HAVE AT.THIS DATE'.A CONTRACT WITH,THE.HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE,WE,R
S'IGNEDTHIS 1L'DAY"OF ' 19 •-• -- " RL36.4,0A ;
OWNER OR ` // T7
OWNERS AGENT O.0:0 O-1 O
ADDRESS •2 O'O 1 „O O ,
F HEREBY ACKNOWLEDGE'THAT I HAVE"READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -6' 4 1 a O 0 6
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
O O
PLUMBING AND SEWERS -I HEREBY CERTIFY THAT) AM PRO PERLY - >
REGISTERED AND/OR /n� 'I �/
LICENSED AS REQUIRED BY LOS ANGLES COUNTY'AND STATE OF '• O S�11 0 /' 9 '
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TORE-
SIDE IN,"THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE / -. '- / Y.�?// �...._. .. ,. •
OF PERMrrT6E= - v