HomeMy Public PortalAbout6050 HART AVE_Sewer__ E-6D83 11.55
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DIVISION OF BUILDING ARID SAFETY -SEWER-SEWAGE D 9SP®SAL
Deportment of County Engineer
County of Los Angeles 'BUILDING ���
JOHN A. LAMBIE, COUNTY ENGINEER u ADDRESS
® CASSATT,D'. GRIFFIN, SUPT OF BUILDING
LOCALITY� ,e m 6?
FOR APPLICANT TO FILL IN
NEAREST T.
�lr
LEGAL
DESCRIPTION 'LOT NO. , � � DOWNER (0. 1
MAIL
BLOCKN� TRACT y o ADDRESS
SIZE F O'f- �' N
�/� NOW ON LOT O. OF BLDGS. CITY TEL. NO.
`o „ /
•,. USE OF DISTRICT�NO. GROUP MAP
BUILDINGS •BK PG
CONTRACTOR
ADDRESS _ CONNECTION DATA
�_5���� z rr�
T/� � /� �� o STATION DEPTH UPPER
CITY L``rEL. N0. J
MANHOLE.REFERENCE
/ / � STATE s
REGISTRATION NO. � f�3{�Q�f� ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF TION LENGTH FROM A -
PUBLIC SEWER - '@ n0 Y. CURB j P.L. M.L. TO P.L. 130 J
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD {�/j "P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO.- I,y�,.�] JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 ^_TRUNK PERMIT NO. 'ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S .00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
DMZ
�O APPROVALS DATE INSPECTORS SIGNATURE
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
A
SIGNED THIS ZZ OCONNECT ADDITIONAL
OWNER OR _BUILDING OR WORK -
OWNERS AGENT
SEPTIC TANK;SEE P,'PIT(5)
ADDRESS AND/OR DRAT NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY,CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND - -
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF
ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEGAL NER OF THE ABOVE
DESCRIBED RESIDENTI 7PERTY.
SIGNATURE d,; BACKFILL SEPTIC TANKS El
- SEEP. PIT(S)'❑ CESSPOOLS /: Cj: /,I,, f.a�
OF PERMITTEE
JOHN A. LAMBIE', COUNTY ENGINEER' VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CASH
CO 6 5-5 8 NOV 12 10 A 5.Q 0 M