HomeMy Public PortalAbout6102 HART AVE_Sewer__ 2D
5 a E-,863 11.55 A P Pe. -A T M N_ . FOR.
P E R , T _
DIVISION
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OF BUILDING AND SAFETY S EYW E R-S EWAG F. D O-S POSA L.
Depwbnent of County Engineer
County of Los Angeles }: BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
27 In-A
® CASSATT D. GRIFFIN,'SUPT OF BUILDING LOCALITY
.:.�ro� i. _,:•»: _. ,, _ - ,;:r• NEAREST ,
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
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' DESCRIPTION - LOT NO.' •] ��� OWNER MAIL
i,.....
BLOCK - TRACT ADDRESS
- //yy NO. OF BLDGS. CITY -TEL. N0.
0C)SIZE OF LOT 4J NOW ON T
USE OFyLBUILDINGSDISTRICTj/" DISTRICT NO. GROUP MAP -
Br_ PG
CONTRACTOR
CONNECTION DATA
ADDRESS
If - STATION ( DEPTH /
CITY TEL. NO. :� G -
I�siATE MANHOLEUPPER
LOWER LOWER
REGISTRATION NO. / /p - n ❑ COUNTY /
NO.. - DESCRIPTION OF WORK� FEE TYPE OF CONNEk;tON, LtAGTH FROM -
HOUSE SEWER CONNECTING TO P'^ y
PUBLIC SEWER @ $3.50 _CURB J( P.L. M.L.TO P.L.
4'
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO,
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 ! CO.,IMP. NO. !OB 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 $ t oo . v 1"11T
AUTHORIZATION TOTAL FEEREIMBURSEMENT FEE-
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I 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. NEW HOUSE SEWER i "Did
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK -•
OWNERS,AGENT SEPTIC TANK,SEEP, PIT(S; -
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE' THAT 'I HAVE READ THIS APPLICATION CESSPOOL ElDRYW ELL❑
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 _ -
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 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT AL ROPERY. > BACKFILL SEPTIC TANKS❑ � � �,,,,
SIGNATURE. SEEP. PIT(s) E-1 CESSPOOL
S I)
OF PERMITTEE '
JOHN A. LAMBIE, COUNTY ENGINEER ALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
V
CK N.0. CASH -