HomeMy Public PortalAbout5831 HART AVE_Sewer__ 76A 642D-CE80.8 A-7/76 L PP �C O1a 11 FOR M
._SEWERi—S.E AGEE DIS SAL LJ
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
FOR
APPLICANT
y
BUILDING AND SAFETY DIVISION
FOR APPA ICANT 1® '`p 'ry DISTRICT NO. GROUP MAP FR ESSED BY
14. LS BK p5
BUILDING
e ADDRESS
` .� CONNECTION DA
LOCALITY
NEAREST _ //� - STATION DEPTH
CROSS ST. /r UPPER
MANHOLE REFERENCE
OWNER TYPE OF CONNECTION LENGTH FROM LOWER
MAIL / -y— Y. CURB P.L. M.L.TO P.L.
ADDRESS l
P.G.NO.
CITY� NO.• CO.IMP.NO. JOB NO. ,
LEGAL F TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I [A56N[NT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING. _
USE OF _ STATE ENCROACHMENT
BUILDINGS 71 PERMIT NO.
CONTRACTOR
G /i/ G✓ vI•_ EAPPROVAL
INDUSTRIAL
WAS
,ADDRECHARGES '
.
C ITY. TEL. NO.
CONNECTION CHARGE FEE
C'STA TE /6• rc-� LIC REIMBURSEMENT FEE
LICENSE NO o[ GLASS
NO. DESCRIPTION OF WOFfK FEE APPROVALS
ALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 1 (n
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO - BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @ SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER '
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL DR-YWELL ❑
'E X TN..CESSPOOL.DRYW ELL.MANHOLE ALTER(.ff_ktAJA,.JSEWER OR
ALTER. OR ABANDON HOUSE SEWAGE DISPOSAL
SYSTEM
SEWER OR DISPOSAL SYSTEM @ II
.. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
'i BACKFILL SEPTIC TANKS .❑
SEEP,PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee' g
' - I HEREBY-ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION �
AUTHORIZATION TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE'LAWS REGULATING,
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING "INTHE
CERT THAT If AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. RE UIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF 19_ R AT I AM THE LEGAL OWN. OF DINT D TO
OWNER OR - HE SO E DESCRIBED R SID - IA P OPERT
OWNERS AGENT n/moi VALIDATION8 9 7,b A
CK, M.O. CASH .
'# O 0'0 O 1.0.
'2'o'o 1 U.00
/4 do
76A642 -64 APPLICATION F'OR PERMO
76A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION tNEAREST
NG `,�
JOHN A. LAMBIE, County Engineer s
WILLIAM A. JENSEN, Sup't of Building
TY /
FOR APPLICANT TO FILL IN ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT P ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROLE D BY
BUILDINGS
BK PG
CONTRACTOR
S� o
ADDRESS Q CONNECTION DATA
CITY TEL. NO. �j�� STATION DEPTH
J I / STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. 1117,o/ - COUNTY -
NO. DESCRIPTION OF WORK FEE TYPE OF CA66:CTION LE TH FROM
HOUSE SEWER CONNECTING TO Y. P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/ DRAINFIELD 510.00 CO.IMP. NO. JOB NO. / C
Q
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. `•
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD, INSTR,NO, DATE I=
WORK TO HOUSE SEWER 53.00 O'
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ S5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING lJJ
SEWER OR DISPOSAL SYSTEM $3.00
STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER/S PERMIT $ 21 Oo
AUTHORIZATION TOTAL FEE eb1 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECT,-RSIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
1 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 THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO ESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER 0
SIGNATURE n Ai• /f
OF PERMITTEE / _ BACKFILL SEPTIC TANKS ❑ ;�I
SEEP.PITS) ❑ CESSPOOLS,0
i.
�.
VALIDATIO ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH
5 9'0 .2 NO 18 1 0 0 7.0Orl cQ'