HomeMy Public PortalAbout6244 HART AVE_Sewer__ 76A64210-62, APPLICATION
PPA ICA" ION FOR PERMIT
78A 642D 1L P`i a �tl FOR PERMIT
Y
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 6UILDING
JOHN A. LAMBIE, County Engineer _ ADDRESS hart St e
WILLIAM A. JENSEN. Supt of Building r I
LOCALITY Tem le Wilt
NEAREST Longden
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL
DESCRIPTION LOT NO. 2 OWNER Powers
MAIL
BLOCK TRACT 5 9Q4
ADDRESS ('1 Blackley
.+ SIZE OF LOT NOWOON LOTS 2 CITYTem le Cit TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCE ED BY
i BUILDINGS 2 Res
BK PG
CONTRACTOR SquareDeal Sewer Service
ADDRESS29'13 Maxson Rd. - CONNECTION DATA
�j
STATION DEPTH
CITY El -Monte TEL. NO. I -20200 STATE _ O , �j�
0 ❑ COUNTYMANHOLE REFERENCE Vj[ UU ER
REGISTRATION NO. EJ
NO. DESCRIPTION OF WORK FEE - YPE OF CONNECTIONLENGT RO ct
HOUSE SEWER CONNECTING TO Y CURB P.L. M.L.T P.L. Q
1 PUBLIC SEWER @ $5.00 OOP.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO.e �
PITS AND/OR DRAINFIELD @- $10.00 ' JOB NO. S
�f
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMILf00��
PRIVATE DISPOSAL SYSTEM @ $3.00 /
CONNECT ADDITIONAL BLDG.OR AFFIDAVITwgIVER egSEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD H
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
.. WASTE APPROVAL
- - - -
OWNER$ PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE OO CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ✓1
TO THE PUBLIC SEWER. APPROVALS DATE INSPE;r-w SIGNATURE
SIGNED THIS DAY OF 19_
'. OWNER OR NEW HOUSE SEWER / �7
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. . CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
1 LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL P�FiOPERTY. ABANDON HOUSE SEWER
SIGNATURE ("� /�j� f/,/s ❑
EE
�///�C//��[[ �y"GC BACKFILL SEPTIC TANKS
OF PERMITT / B -❑
Z- SEEPIS, .PIT(S) ❑ CESSPOOLS '
VALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
L
1.5 2 8 Q0 OCT 16 1 0 D 7.0 0-- q