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HomeMy Public PortalAbout5555 HALLOWELL AVE_Sewer__ ep mem 246 INSERTS /� ` 76AB42D60 APPLICATION FOR PERMIT �eaeazn COUNTY OF LOS ANGELES d 0 SEWER-SEWAGE W��B PERMIT ++ cc 00 DEPARTMENT OF COUNTY ENGINEER BUILDING BUILDING AND SAFETY DIVISION ADDRESS •^1 �") JdHN A. LAMBIE, County Engineer WILLIAM A. JENSEN. Supt of Building LOCALITY 171 NEAREST FOR APPLICANT TO FI4 IN CROSS ST. LEGAL yy s DESCRIPTION LOT NO. OWNER / _ MAIL BLOCK TRACT 1 � •� ADDRESS � NO.OF BLDGS. SIZE OF LOT C)©NOW ON LOT CITY TEL. NO. USE DICT NO. GROUP BK PG MAP PROCESSED BY BUILDINGS DISTRICT CONTRACTOR v -, -El ,/` I ADDRESS CONNECTION DATA - - CITY TEL.NO. STATION DEPTH ., TE MANHOLE REFERENCE UPPER REGISTRATION N0. MANHOLE REFERENCE 5 NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $100 TYPE OF CONNECTIO LENGTH FROM f ITS AND/OR SEPTIC DRAINFGE DT OR @ $ 00 Y. CURB P. M.L.TO P.L. (� OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN..CESSPOOL. DRYWELL @ S1.00 HOUSE SEWER CONNECTING TO /IVC P.C.NO. PRIVATE DISPOSAL SYSTEM @ $ .00 CO. IMP. N0. 7 JOB NO. >. CONNECT ADDITIONAL BLDG.ORTRUNK PERMIT N0. ROAD PERMIT N0. N WORK TO HOUSE SEWER @ $ .00 U SEWER OR OR SYSTEM HOUSE @ 00 STATE ENCROACHMENT - - ca PERMIT N0. d INDUSTRIAL V WASTE APPROVAL WP. CHARGES Ul OWNERS PERMIT 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE .F NA�ED CON- TRACTOR TO CIONNECT THE ABOVE ESCR BED EXIISTDATE A CONTRACT WITH THE IING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER g� SIGNED THIS DAY OF �� J9�y NEW HOUSE SEWER / OWNER OR CONNECT ADDITIONAL v OWNERSAGENT BUILDING OR WORK ADDRESS »' pier s SEPTIC TANK,SEEP.PITS) AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION - AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1ICHEREBY CERTIFY THAT 1 AM PROPER Y REGI�TE D AND/OR DISCONNECT PLUG AND LENSED AS REQUIRED BY LOS ANGELES OUNI'Y AN STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 �(1MTtj LEGAL WNE TH ABOVE ' DESCRIBED RESIDE TIA PRO Y. 1 BACKFILL SEPTIC T=0[] SIGNATURE SEEP. PIT(S) 01 CLS OF PERMITTE ®p VALIDATIOcASH ROBERT A. WOOD cK M.o. SUPERVISING MECHANICAL ENGINEER 76A6420-82 °_82 7APPLICATION FOR PERMIT'` 8A842 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPO AI_ DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY - NEAREST � FOR APPLICANT TO FILL IN CROSS ST. LEGAL DESCRIPTION LOT NO. O. a0 OWNE MAIL � -_ BLOCK TRACT ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY �` TEL NO USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCES BY �� / BK PG CONTRACTOR ADDRESS LGG�-Q r CO^NNECTION DATA CIT NO.'64 6 Ci STATION / ® DEPTH TEL. KJ ElSTATE MANHOLE REFERENCE UPPER �A REGISTRATION NO. Q 3 ❑ COUNTY S LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO p. LENGTH MOM pp� HOUSE SEWER CONNECTING TO Y. CURB M.L. r `b PUBLIC SEWER @ $5.00 SEPTIC TANK,SEEPAGE PIT OR P.C.NO. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. HOUS �C7,E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT I PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1YEE EASEMENT RECORD.INSTR.NO. DATE .0 WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXT N.,CESSPOOL,DRYWE LL.MANHOLE @ $5.00 ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT s CONNECTION CHARGE FEE AUTHORIZATION 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 PU C SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED T DA OF ZO 19_ OWNER OR NEW HOUSE BE FR- OWNERS AGEN CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PITS) I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS 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 ABOVE DES�RIBED RESIDEN IAL PRO_PERTY. ABANDON HOUSE SEWER SIGNATURE , s BACKFILL SEPTIC TANKS ❑ OF PERMITT SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD 6/v SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH 07344w jAN 7 1 0 D 3.o ON