HomeMy Public PortalAbout5925 HART AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELESBUILDING
I
WILLIAM J. FOX, COUNTY ENGINEER !i ADDRESS.
FOR APPLICANT TO FILL IN LOCALITYBUILDING NEAREST
C.
ADDRESS M.25
qQ CROSS ST.
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LOCALITY 1�'�7t DISTRICT NO. SERIAL NO. PERMIT NO. C
NEAREST A 77 4, 5
CROSS ST. A�� nm RECEI VED,RY 0 Ready for Inspection ,-+,DE I UED
OWNER 7//AL e-1
MAIL � � USE ZONE OCCUPANCY BK MAP
ADDRESS PG
CITY TEL.NO.
CONTRACTOR �� � I �r11bCO.IMP.NO.
ADDRESS �� ♦�1xll1L�� Wn bAye JOB NO.
CITY TEL.NO. At.; P 9 TRUNK PERMIT N0.
of STATE EE
REGISTRATION N0. � �,�� - 19 COUNTY ROAD PERMIT NO.LEGAL
DESCRIPTION LOT NO. 40% rt Oar z STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
NOSIZE OF LOT p� qq;qq ► N0W ON LOTS CHARGE
USE OF
BUILDINGS (}(Ql7C°1t3? CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO �1
PUBLIC SEWER @ $ 3.50 -3 ,370 RECEIPT N0. /IO \DATE I BY
HOUSE SEWER CONNECTING TO
l PRIVATE DISPOSAL SYSTEM 1.00
7 ADDITIONALCONNECT BLDG.OR
WORK TOHOUSESEWER100 /j� / EXCEPTIONa�RECORDED
ALTER OR REPAIR EXISTING v s 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 " , DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 7 �/�MANHOLE.REFERENCE
/ R-1 / tiOWER�
TYPE OF CONNECTION! LENGTH.FROM
�Yi CURB) tP,U- M.L.TO P.L.
OWNERS PERMIT $ 1 00 -
AUTHORIZATION TOTAL FEE 15- 5-0
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__�__,(�________-DAY OF_-�v� C�-__._.19_� NEW HOUSE SEWER ��� y0 G7�
OWNER OR CONNECT ADDITIO.NAL
OWNERS AGENTN�Nt
��1 .._.. ��� BUILDING OR WORK
ADDRESS...5.y ...Ver
-- SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL❑
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
1 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 I M THE LEGAL OWN-
ER OF THE ABOVE DE RIBED RE ENAAL PRO ERTY,, BACKFILL SEPTIC TANKS
SEEP.PIT(S)[:] CESSPOOLS � _�
SIGNATURE
OF PERMITTE -'r �i
76A642A 663 7/53