HomeMy Public PortalAbout6242 HART AVE_Sewer__ TEMPLE CHTY
A ISE P�,18®N FOR P WT
COUNTY OF L '`•r�.�X '"T`a C'� l
SEWER-SEWAGg DOSPOSAL
DEPAR--p
TMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engine r ADDRESS r 7`
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
_. - .�.. .. _. .:. .�. CROSS ST.
FOR APPLICANT TO FILL Illi Q
LEGALOWNER
DESCRIPTION LOT NO. �r
BLOCK TRACT MAIL
ADDRESS
sNO.OF BLDGS. .
SIZE OF LOT fJ NOW ON LOT CITY TEL. N0.
USE OF DISTRICT'NO. GROUP MAP PROCESSED BY .•.�
BUILDINGS �. ant p
CONTRACTOR - f� !V BK r, �o
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. ❑ COUNTY ° LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR _P Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
o CONNECT ADDITIONAL BLDG.OR ?
ORK TO HOUSE SEWER @ $1.00TRUNK PERMIT NO. ROAD PERMIT N0.
W _ E
ALTER,REPAIR OR ABANDON HOUSE - STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 " PERMIT NO. '
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT -$ 2 '00 'CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE L/C= 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 CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING a: ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. = SEWAGE DISPOSAL SYSTEM
! I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR a, DISCONNECT PLUG AND _
LICENSED AS REQUIRED BY LOS ANGELES COUNT ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T AT 1 AM THE LE OW E THE ABOVE BACKFILL SEPTIC TANKS ❑
` DESCRIBED RESID IAL PRO ,
SIGNATURE ag% SEEP. PIT(S) ❑ CESSPOOLS
OF PERMITTE
OF VALIDATION ROBERT A. WOOD
CIL X.o. CASH SUPERVISING MECHANICAL ENGINEER