HomeMy Public PortalAbout6016 HART AVE_Sewer__ D
01808- APPLICATION FOR PERMIT
caoe•a-sa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN _CROSS ST,
LEGAL
DESCRIPTION LOT NO. _OWNER
BLOCK TRACT MAIL
ADDRESS
N0, OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT NO. GROUPI MAP PROCESSED BY
�PK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL. NO. STATI0I1,.. DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. El COUNTY
NO. DESCRIPTION OF WORK FEE — LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 —
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L. TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P. C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 _CO.IMP. NO. . JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY.AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER--OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. - BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP, PIT(S) E:1 CESSPOOLS El� `
OF PERMITTEE
®P VALIDATION ROBERT A.WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER