HomeMy Public PortalAbout5918 HART AVE_Sewer__ 78A64213 �_ APpL��CAT�®11�1. 11 ®R PEI!VII. Il
5 �I
&E-868 11.55
DIVISION OF BUILDING ARID SAFETY SEWER—SEWAGE DOSPOSAL
Department of County Engineer -
County of Los Angeles BUILDING /"—
67 JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS i ��� . 91
® S ,,T D GRIFFIN SUPT OF BUILDING LOCALITY
2
FOR APPLICANT TO FILL IN cc"eosss r.
LEGAL OWNER
' DESCRIPTION LOT NO. _ e i)
MAIL
BLOCK - ' TRACT 9 ADDRESS
N0. OF BLDGS. CITY '—'�' TEL. NO.
'• SIZE OF LOT NOW ON LOT
USEOF ... ::.M.�. •,.--•. :.: ., �_:-.. ..,-.�.,•., ,._ .. .-.µ � ,..._ .2:. '.
n BUILDINGS - DISTRICT NO. GROUP MAP
fi CONTRACTOR
S_ CCS•
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
MANHOLE REFERENCE - UPPER
ii-IST AT - LOWER
REGISTRATION NO. 2 ®� ❑ COUNTY
-17
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB - P.L. V.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR "71G 7
n PITS AND/OR DRAINFIELD Q $3.00 d
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE Q $2.00 CO. IMP. NO. _ JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 1 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR' STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM a $1.00 WASTE APPROVAL -
n CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 APPROVALS_ DATE INSPECTOR'SSIGNATURE
f i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ^
TO THE PUBLIC SEWER. NEW HOUSE SEWER /✓
i
SIGNED THIS DAY OF_ 19 S CONNECT ADDITIONAL
OWNER OR -.BUILDING OR WORK _
OWNERS AGENT 2-CA I
SEPTIC TANK,SEEP,PITS) -
ADDRESS - C.,i AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY a CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
.r IHEREBY CERTIFY THAT I .AM PROPERLY REGISTERED AND/OR _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
DISCONNECT ABANDON HO PLUG PLUGUSE AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
WER
DESCRIBED RESIDENTI OLOPERTY. • BACKFILL,SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S)
❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE,COUNTY ENGINEER LIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.0. CASH
fLo 2 s 3 8 APR1 4 4_ 2.O fl