HomeMy Public PortalAbout5233 HALLOWELL AVE_Sewer__ CEBoe 0 APPLICATION FOR PERMIT
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- COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL -
DEPARTMENT OF COUNTY ENGINEER 7
BUILDING AND SAFETY DIVISION BUILDING 3 6 e!� Ave.
JOHN A. LAMBIE, County Engineer ADDRESS f_
WILLIAM A. JENSEN, Supt of Building LOCALITY e7M �c [ L
T I
FO PPLICANT TO FILL IN
•CROSS NEARESST, Gj✓+
LEGAL
DESCRIPTION VL.4 NO OWNER
/� MAIL
BLOCK TRACT O ADDRESS
NO F BL S
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
S
BUILDING
BK PG /
CONTRACTOR a_H414 jel
ADDRESS (P/ &, tI(c(, v CONNECTIO14 DATA
CITY f . TEL NO C�_cs STATION DEPTH
❑ STATE MANHOLE REFERENCE �f
REGISTRATION NO El COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION,,o
M L TO P LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB L O
PUBLIC SEWER @ $5 00
SEPTIC TANK.SEEPAGE PIT OR P C.NO V
PITS AND/OR DRAINFIELD @ $1000 CO IMP.NO JOB NO.
HOUSE SEWER CONNECTING TO TRU E - O E IT O
PRIVATE DISPOSAL SYSTEM CD $300 i , 0
CONNECT ADDITIONAL BLDG OR AFFIDAVI AIVEN EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD 1
EXTN,CESSPOOL,DRYWELL.MANHOLE @ $500
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
.
-PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00
'CONN'ECTION 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 EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE (INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF }9-
OWNER OR NEW HOUSE SEWER �•�
OWNERS AGENT _
CONNECT ADDITIONAL '
ADDRESS BUILDING OR WORK
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
WITH ALL COUNTY ORD fNANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR -
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL• OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV SLRIBED RESIDENTIAL PROP TY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION M O CASH ROBERT A. WOOD
SUPERVISING MECHANICAL-ENGINEER
CK.
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