HomeMy Public PortalAbout10601 HALLWOOD DR_Sewer__ 76A642D 0-63 APPLICATION
DPICATION FOR
PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ineer ADDRESS
WILLIAM AL JENSENCSup't ofnBuilding
LOCAL;TY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL `
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACTVX ADDRESS
NO. OF BLD S.
SIZE OF LOT NOW ON LOT CITY TEL. -NO.
USE OF
BUILDINGS DISTRICT IN GROUP MAP PROCESSED BY
BK PG
CONTRACTOR f D
ADDRESS I•�� jjAA� CONNECTION DATA
CITY / '( TEL. IN / -�j'YY STATION �E DEPTH
❑ STATE, UPPER
REGISTRATION NO. El COUNTY
MANHOLE REFERENCE
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 n'
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
CO,IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 (�
OVERFLOW SEEPAGE PIT,DRAINFIELD - W
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 -
ALTER, 4EPON HOUSE ! HWY. OR ST.WIDENING Z
SEWER GQ^ ��M @ $3.00 > STATE ENCROACHMENT '
- PERMIT NO.
INDUSTRIAL
WASTE APPROV
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION I TOTAL FEE ���1 CON CTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
a TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER7•--
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS I BUILDING OR WORK
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 `
PLUMBING AND SEWERS. - CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY TH I AM PROPE REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRE LOS ANGLE COUNTY`AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA•OR THAT THE LEGAL N R F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DE CRI D RE TIA P PE RT Y. ABANDON HOUSE SEWER
��- SIGNATURE f BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
'
P.
PIT(S) ❑ CESSPOOLS
ALIDATION ROBERT A. WOOD
�i
M.O. CASH SUPERVISING MECHANICAL ENGINEER
� CK.
LACO 5 6 6 31G NOV 6 1 0 D 5.0 0-
IDEPA>ii,TJV ENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
PERMITBUILDING AND SAFETY PERMIT APPLICATION
COUNTY Oe, LOS ANGELES
WILLIAM J. PDX, COUNTY ENGINEER BUILDING / I�r 6! �l V✓`r7
ADDRESS �b����lO D //J�
FOR APPLICANT TO F LL IN ///��� LOCALITY `�s��tt.L/{^�
BUILDING /�� �� o �� NEAREST
ADDRESS U / p CROSS ST.
LOCALITY 7 DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST �5- A +v54_2a S
CROSS ST.
RECEIVED
�BjY, Ready for inspection DATE[ISSUED
OWNER Fz ' 9w
�(D
MAIL
ADDRESS USE ZONE ;EANCY MAP
BK PG
CITY TEL.NO. �•
CONTRACTOR IP
G6s0. `I
ADDRESS '
JOB N0.
CITY17t TEL.NO. G I
TRUNK PERMIT N0.
REGISTRATION NO. c ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. � STATE ENCROACHMENT
PERMIT NO. _
BLOCK TRACT INDUSTRIAL
dam— WASTE APPROVAL
SIZE CF LOT NO.OF BLDGS.
NOW ON LOT" CHAIRGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DEsr_RiPTrbP4 OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
I PUBLICSEWER Q $ 3.50 _ 4! RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTIO RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I . D, TE I 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 /4, DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 1 �ANHOLE REFERENCE
�3 a'/ UPPER LOWER
TYPE OF CONNECTION LENGTH FROM i
OWNERS PERMIT $ 1 00 Ly- CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE / cro
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS--------------------DAY OF_............................._......19..._.._ NEW HOUSE SEWER sr4L 2' T-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT......................................................................_...._.___. BUILDING OR WORK
........._------------------------------------------ SEPTIC TANK,SEEP.PIT(S)
ADDRESS..............
"""""""""'-•"""-------•------ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] 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 I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFI LL SEPTIC TANKS E)
SIGNATURE ,������J //� SEEP.PIT(S)ED CESSPOOLS
OF PERMITTEE_. .0. 4�... �_^__Q f -e ��•
76A642D 663 1/53