HomeMy Public PortalAbout5817 HART AVE_Sewer__ D
S&E-663 11-55 APPLICATION FOR PERMIT 1
S&E•6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles ADDR
BUILDING ��i7
JOHN A. LAMBIE. COUNTY ENGINEER ESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY /��
FOR APPLICANT TO FILL IN ceoss s 4,4LEGAL
-DESCRIPTION LOT NO. t OWNER r'
MAIL
BLOCK TRACT n� ADDRESS ��n
C�'�NO. OF BLDGS. CITYTEL. NO.SIZE OF LOT NOW ON LOT •Z Z F
USE OF �_ DISTRICT NO. GROUP MAP
BUILDINGS I BK PG
CONTRACTOR f9lt'' I I-
CONNECTION DATA
ADDRESS A wv. , /
AP. :_"'� F;^ ��•" STATION (�i-C��' DEPTH
- MANHOLE REFERENCE '001 17 ! QS LOWER`
j STATE
REGIST a,°.;;,,},.. COUNTY
TYPE OF CONNECTION LENGTH FROM „�..
HOUSE SEWER CONNECTING TO P.L. M.L.TO P.L.
@PUBLIC SEWER $' i�' � +sPe'�'_-..—..r••..•_•_.--- ---_ -'r'`
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 - ---
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
_EXTN.,CESSPOOL,DRYW ELL,M AN HOLE C $2.00 � JOB NO.
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM @ $1.00 1TRUNK PERMIT NO. _ROAD PERMIT NN
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER STATE ENCROACHMENT
@ $1.00 _tERM1T NO.
ALTER,REPAIR OR ABANDON HOUSE DUSTRIAL
SEWER OR DISPOSAL SYSTEM c? $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT E 00 ---
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE f ti
_ APPROVALS DATE INSPECTOR'S SIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ -
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR _BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR_DRAINFIELD
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —-- -.-.- -- - -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO USE SEW
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE --
ER
DESCRIBED RESIDE IAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE �t ��ilY/ SE_EP.-PIT(S) ❑ CESSPOOLS _
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.0. CAS
A Jr .
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