HomeMy Public PortalAbout4915 HELEO AVE_Sewer__ i
,°_82
76A642D APPLICATION FOR PERMIT
78A84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS {o
WILLIAM A. JENSEN, Sup't of Building l/
LOCALITY �/M1. T
NEAREST
FOR APPLICANT TO FILL IN CRDSS 5T.
LEGAL
DESCRIPTION LOT NO. OWNER A,, � [
MAIL
BLOCK TRACT r' Z, ADDRESS
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESS BY
{
CONTRACTOR l,( Co 's 0( ...�[O K �� L
ADDRESS 41 q0 f /i o�_/� pQ CONNECTION AT,A{{{���
CITY Qw TEL. NO. US STATION ��� ; / PEPTH
g'--STATE MANHOLE REFERENCE" �" r ` UPPER
REGISTRATION NO. ! ❑ COUNTY
ill CL
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM i^{ O
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. V
PUBLIC SEWER @ $5.00 U
SEPTIC TANK,SEEPAGE PIT OIR d / P.C.NO.
Cie
PITS AND OR DRAINFIELD @ $10.00 CO.IMP.NO. 1 JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00LLI
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DAT a'
WORK TO HOUSE SEWER @ $3.00 N
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $1 21 Oo CHARGES
AUTHORIZATIONTOTAL FEE 64',a CONNECTION CHARGE FEE
iHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER. APPROVALS ATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR ^ j NEW HOUSE SEWER
OWNERS AGENT E W -
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINAj4CES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAVO AM PROPERL REG TERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED LOS ANGLES CO IN AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE LEGAL O NER F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV ESCRIBED RES EN L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILLSEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
r1JUI
,D.82
76A642D APPLICATION FOR PERMI
8A84LJ
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, County Engineer ADDRESS / p
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST 6Lr e Y A
LEGAL µ
DESCRIPTION LOT NO. }f OWNER
MAIL ((
BLOCK TRACT / 3 r��� ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT / CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED eY
` S
CONTRACTOR / L �^ a
ADDRESS �✓ l'c Z( CONNECTION DATA
STATION
CITY L t Q A„� TEL. NO.
"- TATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO- 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM 1 IBJ
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. ) O
PUBLIC SEWER $5.00
SEPTIC TANK.SEEPAGE PIT OR IMP.NO. `_ P.C.NO. V
PITS AND/OR DRAINFIELD @ 510.00 CO. JOB NO. �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR,NO. CfAfE W
WORK TO HOUSE SEWER $3.00 O_
OVERFLOW SEEPAGE PIT.DRAINFIELD N
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5,00 Z
ALTER,REPAIR OR ABANDON HOUSE
HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT
dd/ PERMIT NO.
J INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 60 CHARGES
AUTHORIZATION I TOTAL FEE ' /„i CONNECTION CHARGE FEE
IHAVE 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 INSPECT 'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR ���� f NEW HOUSE SEWER
OWNERS AGENT �✓ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINA ES AND STATE LAWS REGULATING I
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT AM PROPERLY EGI TIERED AND/OR ALTER,REPAIR,SEWER ER
LICENSED AS REQUIRED B LOS ANGLES OU NT AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A THE LEGAL O ER , AND INTEND TO DISCONNECT PLUG AND J
RESIDE IN, THE ABO E SCRIBED REST ER
P OPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
3471 JUL ' ^ D2 S J
�I