HomeMy Public PortalAbout6121 HART AVE_Sewer__ S&E•663 3-55 APPLICATION FOR PP.RMIT _
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I S POSA L
Department of County Engineer
County Of LOS AIIgeI08 BUILD�LO�CALITY
BUILD
-DREG y-( Q✓tom (L'.o-C!
WM.J. FOX, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING
FOR APPLICANT TO FILL IN CROSS sr. GciLiGc�i�
LEGAL fI
DESCRIPTION! LOT NO. ,-s�-/ 7 �'" �c� OWNER - /
BLOCK13
TRACT �j ADDRESS
// NO. OF BLD7GS. �� n �`�
SIZE OF LOTS. 4 D X iUSE OF �� NOW ON LOT G 7�.+L CITY ;�,,.y a TEL. NO.
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4, BUILDINGS '. e'�! r''Y►--(L� DISTRICT NOS G�(OUP MAP
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CONTRACTOR ��� I r_- P�
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ADDRESS /- �4 % f S' / _ CONNECTION DATA
CITY �. �-�� TEL. N0. yC- �d� STATION �£•.�kly DEPTH �• O
❑ STATE MANHOLE REFERENCE gr (� UPPER
REGISTRATION NO. �. )' E3 COUNTY_
- OL' �`J
NO. DESCRIPTION OF WORK FEE
TYPE UR O ECTION LENGTH 6
JLHOUSE SEWER CONNECTING TO Y. P.L. M.L. TO P.L..L.
PUBLIC SEWER cQi $ 3.50 3 1!ra
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. ORP. C. N0.
WORK TO HOUSE SEWER 1.00 _ CO. IMP. NO. (/ q JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 -TRUNK PERMIT N0. ROAD PERMIT NOUX?'Ifear
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT H0.
SEPTIC TANK, SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 1 00
AUTHORIZATIONTOTAL FEE A REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN AHED CQOfN-
TRACTOR t0 CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEC40iR S SIGNATURE
TO THE PUBLIC SEWER - < - 1 E
NEW HOUSE SEWER
SIGNED THIS-1--DAY OF I -' 19
OWNER OR .Q,�/ ` CONNECT ADDITIONAL
OWNERS OF „ BUILDING OR WORK
ADDRESS O Q`� `- "✓"� SEPTIC TANK, SEEP, PIT(S)
. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE.READ THIS APPLICATION CESSPOOL El DRYWELL[I
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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY• BACKFILL SEPTIC TANKS❑ /
SEEP. PIT(S) C3CESSPOOLS �-�_(.�•Tiy� /`%,�'(fd'A4'L'f
SIGNATURE
OF PERMITTEE
WILLIAM J.FOY-COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
` ;'IC0 5 3 8 0- APR 2 4 4 4.5 0