HomeMy Public PortalAbout6272 HART AVE_Sewer__ 10-82
76AG42D A T– – ICATOOAFOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY, DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST
LEGAL IL
FOR APPLICANT TO.FILL
L IN CROSS ST.
F
DESCRIPTION LOT NO.N—
eJ�5''� AGO OWNER MAIL s-' /J ry � �BLOCK TRACT ADDRESS ' v(/f
NO..O F..BLDGS. - -��
SIZE OF LOT NOW ON LOT CITY �� STEL. NO.
USE OF
BUILDINGS DISTRICT_N O. GROUP MAP PROCESSED BY -
-' BK PG
CONTRACTOR' !' J (/'�' �.•��
.ADDRESS CONNECTION DATA_
CITY „� 1,;,',/EL. NO STATION DEPTH
STATE MANHOLE REFERENCE - UPPER
- 'REGISTRATION NO. COUNTY
NO. DESCRIPTION. OF WORK FIEE_ TYPE OF c TION LENGTH-FROM _
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.To P.L.
PUBLIC SEWER @ $5.00 _ P.C.NO. _ V
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $70.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM @ $3.00 y`J
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOU
5E SEWER @ -$3.00 _ - - -----
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRY,WELL,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 .. ... .. _.. ...
- - - CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION rj6TAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING_DWELLING
TO THE PUBLIC SEWER.. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF .19—
OWNER
19_OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 'I HAVE READ THIS APPLICATION AND/OR GRAINFIELD _
AND STATE THAT THE A'BOV.E IS.CORRECT AND AGREE TO COMPLY -
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. - CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A T OWNER OF, AND INTEND TO DISCONNECT PLUG AND -
RESIDE IN, THE AB,VE ESCR D RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
E _ BACKFILL SEPTIC TANKS ElOF PERMIT ❑ �p.@.
.. - SEEP,PITEl CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
7 -: 0 6� JAi,..- 1 1. 0 D .7.0 0-