HomeMy Public PortalAbout4824 HELEO AVE_Sewer__ ;E808. D
eaoa. APPks=�CAT� N F®IlU II ERIlk/IIBT
a-ss COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER .,
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSAIT D. GRIFFIN, Sup t of Building LOCALITY
.'. : .. -`FORAP .. NEAREST Ob4fd'v
PLICANT TO FILL IN CROSS ST.
LEGAL •�. Q OWNER
DESCRIPTION/ LOT N0. r3� J _
p (o� .� MAIL �..
BLOCK TRACT ADDRESS �( S
NO.OF BLDGS.
SIZE OF LOT ,� NOW ON LOT' CITY TEL. N0.
USE OF :.- r •.'s.� .>v >, �..
BUILDINGS - DISTRICT N0. GROUP n MAP '-P OCESSED BY
�r BK PG
v CONTRACTOR V/ I IQ .4-
ADDRESS
ADDRESS 3 ` CONNECTION DATA
CITY TEL.NO. 6-7,95-3 STATION 3j_ DEPTH
• ❑ STATE MANHOLE REFERENCE i! UPPER
REGISTRATION NO. ❑ COUNTY ' Y-•
,• No. DESCRIPTIO OF WORK FEE
�. / HOUSE SEWER CONNECTING TO
I PUBLIC SEWER @ $3.00 -f�
TYPE OF TION LENGTH FROMSEPTIC yS
� PTS AND/OR DRAINFGELDPIT OR @ $3.00 .t Y. O=
P.L. M.L.TO P.L. o�
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL. DRYWELL @ $2.00
ti HOUSE SEWER CONNECTING TO ` P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 =• CO.IMP: NO. 4? JOB NO.
WORK CTTO ADDITIONALOUSE LDG.OR @ $1 00 TRUNK PERMIT NO. ROAD PERMIT N4?
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL ,
WASTE APPROVAL '
CHARGES
OWNER'S PERMIT $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q(9 REIMBURSEMENT FEE
I HAVE AT THIS DATE A WITH THE HEREINCON-
TRACTOR TO CONNECT THE AB VET DESCRIBED EXISTINGgMED DWELLIING APPROVALS DATE. INSPECTOR'S SIGNATURE
TO THE PUBLIC�SEVPER.
SIGNED THIS�4_ AY NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL Y
OWNERS AGE NT - BUILDING OR WORK
•' ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ TIJA APPLICA I N
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY CESSPOOL ❑ DRYWELL ❑
WITH�ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
e. PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1ICHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _-
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF '- ABANDON HOUSE SEWER
' CALIFORNIA OR-THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEtIAL PROPERTY. '^E _ BACKFILL SEPTIC TANKS ❑ :. .
SIGNATURE „sJ�7�y� SEEP.PITS) ❑ CESSPOOLS'❑
OF PERMIT TE �•!�✓
VALID-VALIDATION
ATION ROBERT A. WOOD ,
M.o. CASH SUPERVISING MECHANICAL ENGINEER
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