HomeMy Public PortalAbout5613 HALLOWELL AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL, 1
r DIVISION OF BUILDING AND SAFETY` PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUIDLO'RESSNG
` AD
FOR APPLICANT TO FILL IN LOCALITY
BUILDING � �� CROSS ST. �/
AD3RENEAREST
SS �"
LOCALITY ) �C!" DISTRICT NO. A SERIAL NO. �jPEER"MIT NO.
NEAREST Z /!/ e f0 IA/� !M` i— I DEQ
CROSS ST. RECEIVED BY Ready for Inspection I pIAE ISSUED
OWNER � • G/MAIL
ADDRESS) a /1 ��/ �„� USE ZONE~ OCCUPANCY BK MAP PG
CITY CF71/`I1# TEL.NO.
CONTRACTOR Ir , CO.IMP.NO. ,
ADDRESS �„r'
JOB N0.
CITY Al .O TEL.NO. TRUNK PERMIT NO.
_
REGISTRATION N0. f .� �- TATE[].COUNTY ROAD PERMIT NO.
LEGALtt
DESCRIPTION LOT NO ,?e d e ® ��p STATE ENCROACHMENT _
PERMIT NO.
BLOCK TRACT '� ., fi
WASTES AAPPROVAL
SIZE OF LOT / I NO.OF BLDGS.
NOW ON LOT CHARGES
QO
USE
-BUILDINGS CONNECTION CHARGE FEE
� S
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 Z RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO DATE BY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 2.00 STATION gel. r; DEPTH rj
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 imm
i, n MANHOLE REFERENCE OWEti
TYPE OF WCTIO& LENGTH ROM 'a
OWNERS PERMIT $ I 00 " �"�' � M.L.To P.L.F
AUTHORIZATION I TOTAL FEE .�7)
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
�. C
SIGNED THIS..........,::..__DAY OF .____ ...................19 NEW HOUSE SEWER �� �` •'
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT......... BUILDING OR WORK
r SEPTIC TANK,SEEP.PIT(S)
ADDRESS................ -------------y .......................... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[:] DRYWELL E]
CA
TICN AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS I]
SIGNATURE SEEP.PIT(S)[] CESSPOOLS
� f G!�'7"_
OF PERMITTEE-•-- =- - ........-...... --- - - - - - I
76A642A 663 7/53 V