HomeMy Public PortalAbout6236 HART AVE_Sewer__ E806 D
CXV II P Imo-�C®"`t T I O N FOR PERMIT
ESDB 8.58 �
COUNTY OF LOS ANGELES SEWER--SEWAGE D19POSAL �
DEPARTMENT OF COUNTY ENGINEER �Ms E44
BUILDING AND SAFETY DIVISION FADDLDING ; 4�
RESS
JOHN A. LAMSIE, Count� Engineer
CASSATT D. GRIFFIN, Supt of Building ALITY ">�
_FOR APPLICANT TO FILL IN AREsrss sr.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT JMAIL
ADDRESS .
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT _ CITY TEL.'NO.
USE OF '
DISTRICTN0. GROUP PROCESSED
B'MAP P SD BY
BUILDINGS -.i°1'�"' f/a'''�/ E
A CONTRACTOR f � /
ADDRESS ; CONNECTION DATA
CITY TEL.N0. r 3 STATION DEPTH
Art> 0
e STATE MANHOLE REFERENCE �® UPPER
REGISTRATION N0. - ❑ COUNTY
NO. DESCRIPTION F W RK PEE
,j HOUSE SEWER CONNECTING TO -
/ PUBLIC SEWER @ $3.00 TYPE OF ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. C RB- P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD -@ $8.00 -
OVERFLOW SEEPAGE PIT,'DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. - -
_ PRIVATE DISPOSAL SYSTEM @ $1.00 CO.I P.N0. JOB NO. '
'A
CONNECT ADDITIONAL BLDG.ORTRUNK PERMIT NO. ROAD PERMIT NO.
U WORK TO HOUSE SEWER @ $1.00 _ e
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT '
SEWER OR DISPOSAL SYSTEM @ $1.00 - PERMIT NO. '
INDUSTRIAL
WASTE APPROVAL -
CHARGES. -
OVMER'S PERMIT $ 2 QC CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE d REIMBURSEMENT FEE.
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT.THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY.OF 19_ NEW HOUSE SEWER•
OWNER OR ,/yp� CONNECT ADDITIONAL
OWNERS AGEjjNTgg' BUILDING OR WORK
ADDRESS it SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE.THAT 1 HAVE READ THIS AP LICATION -
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
A HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS
,ANGELES COUNTY AND STATE OF ABANDON HOUSE DISCONNECT CTPLUG PLUGWER
AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED EERESIDENT A PROPERTY. �— B EP.PITIC TANKS [399 '0
SIGNATURE TS) CESSPOOLS C
OF PERMITTE � .
®" VALIDATION, ROBERT A. WOOD
CIL M.o. f CASH SUPERVISING MECHANICAL ENGINEER
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