HomeMy Public PortalAbout5563 HALLOWELL AVE_Sewer__ 76A 6420 - CE808 - 9/73 APPLICATI ®� �1'r'
COUNTY OF LOS ANGELES SEWER—SEVYE DISPOSAL �J
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESSt6 j
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. fAl
LEGAL
DESCRIPTION LOT NO. (J OWNER
MAIL
BLOCK TRACT U L ADDRESS
NO. OF SLOGS. �1�
SIZE OF LOT NOW ON LOT CIT TEL. NO. C�'�-
USE OF DISTRICT N GROUP MAP OCESSED BY
BUILDINGS BK PG
CONTRACTOR
6 Ak 3
ADDRESS CONNECTION DATA
CITY TEL. N0. STATION67-37
DEPTH
STATE MANHOLE REFERENCE LIC 47 f UPPER
LICENSE NO;, L C C"
R
No. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO !'V Y. CURB ���a M.L.TO P.L.
PUBLIC SEWER 6 $7.00 V
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB N0.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE r
WORK TO HOUSE SEWER ® $3.00 O.
OVERFLOW SEEPAGE PIT.DRAINFIELD c:)
EXTN..CESSPOOL.DRYWELL. $5.00 G.7
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING -
SEWER OR DISPOSAL SYSTEM $3.00 CD
ENCROACHMENT
MANHOLE $7.00 PERMIT NO. V
W
INDUSTRIAL p�
`a��. WASTE APPROVAL cn
OWNER'S PERMIT $ 3 00 CHARGES
AUTHOMATION TOTAL FEE /) CONNECTION CHARGE 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 19_ w
OWNER OR NEW HOUSE SEWER „ ie '(Jr r-v �/jL�
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PITS)
I HEREBY ACKNOWLEDGE THAT I 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 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND'STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC,RNIA OR T AT I AM THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A 0. D THE
SIDENT PR TT. ABANDON HOUSE SEWER
SIGNATURE
OF PEfi Mrl BACKFILL SEPTIC TANKS ❑ ❑
*T SEEPy�*PIT IS
ESSPOOLS
VALIDATION CK. M.0. CASK
0 1 2r"-'AUG 13 10 D 1 0.0 0 ��a