HomeMy Public PortalAbout5604 HALLOWELL AVE_Sewer__ E°Oe 12-°e
76A 642D APPLICATION FOR PERMIT -
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SuP•T. OF BUILDING y,
LOCALITY z T 1
NEAREST
FR
R APPLICANT TO FILL IN `ROSS ST.
LOT NO. OWNER '� �,IC
MAIL
TRACT CF
7 yY/ Y ADDRESS , �=�(-
/ / NO. OF BLDGS. t
NOW ON LOT CITY TEL.
DISTRICT NO. GROUP MAP PROCESSED BY
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CONTRACTOR N` :./ ,
ADDRESS :/ CONNECTION DATA
STATION DEPTH Ci
CITU, TEL. NO. j
STATE LIC MANHOLE REFERENCE f
LICENSE NO. CLASS zooyyg�
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION P.L. FL
OM FOM ��jj �f
HOUSE SEWER CONNECTING TO .� Y. CURB M.L.TOP. �J` ,
PUBLIC SEWER a 55.00 fJ L
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO �-
PRIVATE DISPOSAL SYSTEM Q 53.00 TRUNK PERMIT NO. ROAD PERMIT NO. a
O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1YE■ [AS[M[MT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD _ �
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING _ W
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT d
PERMIT NO. C.n
Z
- INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E 2 00
AUTHORIZATION I TOTAL FEE loe? CONNECTION CHARGE FEE
I HAVE 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-1 9-
OWNER OR NEW HOUSE SEWER - T
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM 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, TH -AB VE DESCRI QED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE I �i ❑
OF PERMITTEE - -Z 'I.f��_ BACKFILL SE TI ANKS
SEEP.PIT IS) CESSPOOLS
�7. VALIDATION JACK R. ALLEN
CK
M.0 cgsH SUPERVISING MECHANICAL ENGINEER
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