HomeMy Public PortalAbout6024 HART AVE_Sewer__ CE808 3-64
76A642D /"ilrrL f"a II N FOR PERMOT
COUNTY OF LOS ANGELES 4 SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ® /
JOHN A. LAMBIE, County Engineer AD
WILLIAM
/
WILLIAM A. JENSEN, Sup't of Building i
LOCALITY A
NEAREST /j'S ��'i
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL
DESCRIPTION LOT NO. OWNER "
MAIL
BLOCK TRACT ADDRESS
NO. OF BL0GS.
SIZE OF LOT NOW ON LOT CITY TEL. -NO.
USE OF
BUILDINGS CDISTRICT
)IST R/I/fJC�T/N��JO. GRO MAP PROCESSED
^,BY
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CONTRACTORled h�z :/, l! (J --- J .. - �L,,�,/c
ADDRESS �� r CONNECTION DATA
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CITY TEL. NO. _ ® / F TION O ) DEPTH
REGISTRATION NO. L- cf 7 ❑ COUNTY MANHOLE REFERENCE R STATE ,% ' ,.LOWER
NO. GESCRIPT ON OF WORK FEE PE OFNN / LENG FROM
HOUSE SEWER CONNECTING TO Y ��+, 1/ M.L. O P.L. CJ
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. }
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. a
HOUSE SEWER CONNECTING TO ry I O
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO.j �{ ) U
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Y/AIVER I EASr M[MT RECORD,INSTR,NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 V
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING IJ.!
O_
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT H
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE 900 CONNECTION CHARGE FEE CHARGES
'IHAVE AT THIS DATE A CONTRACT'WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPE ATO R'S SIGNATURE
SIGNED THIS DAY OF 19_ t
OWNER OR NEW HOUSE SEWER IMAIr�17 I � r
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I 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 I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THELEGAL OWNE F. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RES IDEN IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ///� ��/) BACKFILL SEPTIC TANKS
5 ❑
OF PERMITTEE Ly'1.� C]SEEP,PIT(S) El CESSPOOLS
,VALIDATION
ROBERT A. WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
Lk1036Q31 OGT 41 0 G 17.00
12
76A64 D APPLICATION FOR PERMIT
76A642D COUNTY OF LOS ANGELES _ IVL j�
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE L fLll
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
ell
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICAN O FILL IN GROSB ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT �, ADD SS
NO. OF BLDGS.
SIZE OF LOT / OW ON LOT CITY TEL. .NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR / /� z--- - /
ADDRESS G". •:r< J CONNECTIOIIIN///DATA
CITY TEL. NO. /IONS DEPTH ,{'
i L /// CJ
REGISTRATION NO.
❑ CCOUNTY MANHOLE REFERENCE / E LOWE
NO. DESCRIPTION OF WORK FEE TYPE OF CONN T LENGTH OM
HOUSE SEWER CONNECTING TO Y. M.L.TO L.
PUBLIC SEWER @ $5.00
P.G.NO. >"
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. / 1.0. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE a
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT.DRAINFIELD ~
EXT N.,C ESSPOOL,DRV WELL.MA NHOLE @ $5.00 V
HWY.OR ST.WIDENING
ALTER,RE IR OR ON HOUSE Lll
a
SEWER ISP TEM @ $3.00 STATE ENCROACHMENT y
v PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL Q
OWNERS PERMIT s CHARGES
AUTHORIZATION TOTAL FEE
a CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE ,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS,�, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE S20
OWNERS AGENT ..
CONNECT ADDIT NAL ✓
BUILDING OR WORK
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLYG T RED AND R ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BV ANGLES UN NO ST OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A HE EGAL N AND 1 TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE MEDD
PROPE ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(S) ❑ CESSPOOLS
�LIDATIONM.0. 0ASH ROBERT WOOD
SUPERVISING MECHAA NICAL ENGINEER
M.O. C
i 0 1 0 5 7' OCT 4 11 D 25-0u-