HomeMy Public PortalAbout4945 HALLOWELL AVE_Sewer__ 76A 6421) - C.E808 - 9/73 APPL.ICAT ON FOR PgRMIT I I
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
ING
SS
ITY
FOR APPLICANT TO FILL IN 7. 7
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT G •� ADDRESS
NO. OF BLDGS.
SIZE OF LOT ev
NOW ON LOT CITY TEL.
USE OF DISTRICT NO. GROUP MAP OCESSED BY
BUILDINGS hh BK PS
CONTRACT. V
ADDRESS CONNECTIO DATA
STATION y DEPTH
CIT TEL. NO. GJ
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO;_ GLASS s
NO. DESCRIPVION OF WORR FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO " Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00 U
SEPTIC TANK.SEEPAGE PIT OR P.G.NO.CO.IMP.NO. JOB NO.
PITS ANDI OR DRAINFIELD @ SIO.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PER
PRIVATE DISPOSAL SYSTEM $3.00
CON NECTADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENt RECORD.INSTR.N DA
WORK TO HOUSE SEWER ® $3.00 d.
OVERFLOW SEEPAGE PIT.DRAINFIELD COl
EKTN.,CESSPOOL,DRYWELL. @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING C
SEWER OR DISPOSAL SYSTEM $3.00O
STATE ENCRO�ACH�1�EN //('
MANHOLE Q $7.00 PERMIT NO. /O
INDUSTRIAL
WASTE APPROVAL
PERMIT
CHARGES —
OWNER"S s
AUTHORIZATION TOTAL FEE f CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED KISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS OF 19_
OWNER OR NEW HOUSE SEWER �Y-7;
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
I HEREB CERTIFY THAT 1 AM PROPERLY R GIST ED
TAN DE
ALTER,REPAIR.SEWER OR
LICENSE. AS REQUIRED BY LOS ANGLES CO TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCdt b THAT I AM THE AL OWNE OF, AND INTEND TO
RESIDE N, T ABOVE DESCR REST E L ROP RTY. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNA R ❑
OF P MfTTEE BACKFILL SEPTIC TANKS
SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATION CK. M.0. ASH
9 8 0 i--mm 3 1 1 5.0 0 L%