HomeMy Public PortalAbout5627 HALLOWELL AVE_Sewer__ 7 6%64213 APPLICATION FOR PERMIT
COUNTY-OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING q
JOHN A. LAMBIE, County Engineer ADDRESS o/
WILLIAM A. JENSEN, Sup't of Building
LOCALITY �
...__ .... _..a :. NEAREST
FOR APPLICANT TO FILL IN CROSS sT.
LEGAL
DESCRIPTION LOT NO. OWNE
V p,(��� MAIL
BLOCK TRACT .��/" ADDRESS
NO. OF BLO GS. s _
SIZE OF LOT ! NOW ON LOT CITY
USEOF �y DISTRICT NO. GROUP P PROCES D BY
BUILDINGS ` C"
BK PG
CONTRACTOR �;'� 0-/1 Al
.�
ADDRESS ,� f,� f !llddd CO CTION DATA
�J STATION DEPTH
❑ STATEMANHOLE REFERENCE UPPER
REGISTRATION NO. ElCOUNTY - LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. a
PITS AND/OR DRAINFIELD @ $10.00
CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR l AFFIDAVIT 11 E.SEMENT RECORD. INSTR. NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT.DRAINFIELD V
EXTN„1ESSPOOL,DR1WELL,MANHOLE @ $5.00 LU
ALTER.&6i3' "^" '�'"ate'HOUSE HWY.OR ST.WIDENING a
SEWER O&:9T4P0"0"--SYSTEM @ $3.00 STATE ENCROACHMENT h
! PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s 2 00
AUTHORIZATION TOTAL FEE 11 CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER'
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS -
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
PCESSPOOL ❑ DRYWELL El AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RE2SPFR,SEWER OR a /!-
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF S�EWPA'BE Di SYSTEM - V/L�� f.J11-
CALIFORNIA OR THAT I AM THE LEGAL O ER OF, AND INTEND TO
RESIDE IN, THE ABO E D SCRIBED E5 NTIA PROPERTY. DISCONNECT PLUG AND !,
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION--, ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
idf 'z 9 3 2 AuG 3 1 C) D .0
y DEPANrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND, SAFETY PERMIT APPLICATION ® a
4' COUNTY OF LOS,ANGELES
f WILLIAM J. FOX. COUNTY ENGINEER I BUILDING �v+a'/
ADDRESS z fp /
FOR APPLI ANT TO FILL IN LOCALITY
BUILDING / �J NEAREST p
ADDRESS LP C2- / CROSS ST. �, -
LOCALITY �fa� DISTRICT N0. SERIAL N0. PERMIT NO. c
NEAREST I v A (6 SCJ d� S
CROSS ST.
+.fit , h r/RECEIVED BY Ready for Inapeetion f DATEISSUED
OWNER 1 trtLlLn r v C�II . 4�t� 1�/L ! l—1 �
MAIL USE ZONE OCCUPANCY MAP
-ADDRESS BK PG
CITY TEL.NO, py /� I �c
CONTRACTOjUali,f ornia Sewer Cons$o 00e
CO.IMP.N0. �- 1
ADDRESS 1317 C01egrove AVe o JOB NO. Ib�
CITY Wont ebe110 TEL.NIdNion 1-50481�
•o � TRUNK PERMIT N0.
REGISTRATION N01O4445 S2 }. STATE
c�}.@OUNTY ROAD PERMIT NO. Y-.,_
LEGAL
�
� �� 4
DESCRIPTION LOT N0.�/m(/�Tt/4`" / STATE ENCROACHMENT I6
t Q PERMIT NO.
BLOCK TRACT��, 1 l tB«i I INDUS APPROVAL
N0.OF BLDGS. �✓
SIZE OF LOT?D X NOW ON LOT CHARGES.
USE
BUILDINGS
CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
J PUBLIC SEWER @ $ 3.50 c� �u RECEIPT NO-,,,, I'By
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM I.00
CONNECT ADDITIONAL BLDG.OR &X EC EC PTIO R CORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO I DATE `Ip&
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_AND/OR DISPOSAL SYSTEM 1.00 -CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR �N
PITS AND/OR DRAINFIELD 2.00 STATION .�Gy��l DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 J� / MANHOLE REFERENCE /
C� JRPER •0' LOWER
TYPE OFCONNECTIONS� LENGTH FROM /�
OWNERS PERMIT ; 1 pp _y_ � �_P" M.L.TO P.L. 4 O
AUTHORIZATION TOTAL-FEE
I 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 /
SIGNED THIS 130 T _.DAY OF---� ...? ...19_-�O NEW HOUSE SEWER za-Z-A
OWNER OR _ CONNECT ADDITIONAL
..
OWNERS AGENT. !__ -__ __-- ________ BUILDING OR WORK
__1--_• -'.L� SEPTIC TANK,SEEP.PIT(S)
ADDRESS-- 4 ✓-v AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL I] DRYWELL E]CATION 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 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
OF PERMITTEE`�r�!.� .r._ �.�S� i C.�Jt.f__-.i......._ SEEP.PIT(S)o CESSPOOLS p6
SIGNATURE ,
:sr
76A642D 663 1/53 001