HomeMy Public PortalAbout4944 HALLOWELL AVE_Sewer__ 76%642D
CEBDR(REV 6/78)
APPLICATION"-,FOR PE R,M IT ', ',
'
®s > . '
_ SEWER — SEWAGE DISPOSAL"
y COUNTY OF LOS ANGELES BUILDING AND SAFETY.
rDISTRICT NO-'• GROUP '. �, j7•��MAP 'I•. `PROC ED BY -
FOR
/APPLICANT
TO FILL-IN' " �t
BUILDING `"/ os _ -i--+. T� `�� ,
ADDRESS /
G CONNECTION DAT
LOCALITY ,
NEAREST
STATION '!S'.' I- F�1'D_EPTH•
CROSS ST: UPPER
MANHOLE REFERENCF/D fav •7 ,,,5"7�+ LOWER
OWNER /� Li Ci IL� - t. y.. r t
TYPE OFC CTION LENGTH FRO `
MAIL •��� �� V CURB' - P L -
ML.TO PL
ADDRESS .' a � •- ,
CO.IMP NO. o�- '' 'JOB NO
CIT-Y, TEL.NO
LEGAL - TRUNK PERMIT NO • .ROAD PERMIT N6.`9rp_OD
DESCRIPTION LOT NO
•AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO' DATE
BLOCK TRACT
NO.OF BLDGS. -
SIZE OF LOT !• NOW ON LOT HWY-,OR ST.WIDENING ,
USE OF STATE ENCROACHMENT'
BUILDINGS .� �� J� PERMIT NO.,INDUSTRIAL
'
CONTRACTOR 4 `,G YT /C`"��� i�� WASTE APPROVAL '
ADDRESS-' _S ,�� CHARGES
CONNECTION CHARGE FEE
CITY TEL NO
STATE LICAS'S REIMBURSEMENT FEE
LICENSE NO - CL
NO. DESCRIPTION OF WORK FEE 1, APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO'
PUBLIC SEWER _ / NEW-HOUSE SEWER .30
SEPTIC•TANK.SEEPAGE PIT-OR < --• -y �• -
PITS AND/OR DRAINFIELD . CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK -
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR, SEPTIC TANK,SEEP,PITISI
-
WORKTO'HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [jDRYWELL Cl -
EXTN.CESSPOOL;DRYWELL.MANHOLE -,
' ALTER.RREPAIR OR ABANDON HOUSE ALTER.•REPAIR:SEWER OR -
SEWEORDISPOSALSYSTEM 11 SEWAGE DISPOSAL SYSTEM -
'1 DISCONNECT PLUG AND
ABANDON HOUSE SEWER ,
BACKFILL SEPTIC TANKS-Q•-
-
_ SEEP,PITISI El CESSPOOLS El •1^
OWNER'S "Permit s '
AUTHORIZATION' ` TOTAL'FEE' - ' " VALIDATION '
`
I.HAVE,AT THIS DATE A CONTRACT WITH-THE HEREIN-NAMED CON- •-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING'DWELLING - - Z �I/y"� (1 ,
TO THE PUBLIC SEWER. - V 4� ll
SIGNEDTH'I'S �"�•" --DAYOF �i�, "• 19_ , ' - M O o O o'�.� i••
OWNER ORL�G / !�- . -
OWNERS AGENT - .,. .• - p -
ADDRESS
'2 0"01
'-I HEREBY ACKNOWLEDGE'THAT'I HAVE READ THIS'APPLICATION '" ;OHO O 1 �,,�O
AND STATE THAT THE�ABOVE IS CORRECTaAND AGREE TO COMPLY ,
WITH ALL COUNTY ORDINANCES AND STATE` LAWS REGULATING -'
PLUMBING AND SEWERS -'r - - -" - ' " ' _�7 9
I HEREBY.CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 4Y / 'Y
LICENSED AS REQUIRED-BY LOS ANGELES'COUNTY AND STATE OF -
CALIFORNIA OR THAT 1 AM,THE LEGAL OWNER OF.AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL R ERTY ,
SIGNATURE-
OF
IGNATURE• �C.�� .
OF PERM rrTr.1 2