HomeMy Public PortalAbout4923 HELEO AVE_Sewer__ 1'68 E486312.54 A® tl LICN`-llTPON.•N O PERMIT
DIVISION OF BUILDING AND SAFM SEWER-SEWAGE D O S POSA L ��
Department of County Engineer
County of LOS Angeles BUILDING9MAP
WM.J. FOX, COUNTY ENGINEERADDRESS �}-CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITT `/ ,����` �FOR APPLICANT TO FILL IN CROSS ST 42LEGAL IDESCRIPTION LOT NO. - OWNER � < ��BLOCK TRACT- A R��^���j-'0 ��"� MAILADDRESSN0.OFBLDGS.SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT NO. I GROUP
/ BK PG
CONTRACTOR �7G / �� � �\/y�� �/®�j_ slry �—/�
ADDRESS 13 i`7 ?IQ e � iii s CONNECTION DATA
CITY A�j�� i`TEL. NO. STATIONy� tji DEPTH
f-� ❑ STATE , G MANHOLE REFERENCE
REGISTRATION NO. UNTY ✓ UPPER LEER
TYP j•�NECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURBJJ P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWERcCil $ 3:50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0.
1.00 Y /6 JOB. NO.
_ WORK TO HOUSE SEWER
ALTER OR REPAIR EXISTING /
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
'DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
.CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OmnmlS PERMIT $ 1 00
AUTHORIZATION TOTAL FEEFIT
REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH.THE HEREIN NAMED CON- 11
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECT OR'sS1GN�A7UR'E
,TO THE PUBLIC SEWER _ ,`
SIGNED THIS DAY OF 19NEW HOUSE SEWER
OWNER OR � - CONNECT ADDITIONAL /
OWNERS AGENT I`�// BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S) - -
ADDRESS ANIAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL Cl DRYWELL El
AND STATE THAT THE ABOVE IS CORRECTAND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEGAL OWNER OF THE ABOVE
DESCRIBED RES EN AL PE BACKFILL SEPTIC TANKS❑
SEEP.,PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERM ITT
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION A
BY .a. 4
l 6 O 9 tr, MAR 15 4-50BY
� .
DEPUTY pp DEPUTY
B7 BY �� i���!/!/�LCXi� ✓ ,
`.® DEPUTY DEPUTY
CE808 3-64
APPLICATION76A642D FOR
PERMIT ERMIT
�71
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1'LIII
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS p
WILLIAM A. JENSEN, Sup't of Building /
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRD66 9T.
LEGAL
DESCRIPTION LOT NO. OWNER
e-7 MAILL
/C
BLOCK TRACT ✓C ADDRESS
NO. OF BLDGS.
SIZE OF LO NOW ON LOT CITY TEL. -NO.
USE OF ... _. _ ..
BUILDINGS DISTRICT NO. GROUP M
BK AP PROCESSED BY
PG
CONTRACTOR �' (/ 1 4::5, D 'O
ADDRESS CONNECTION DATA
STATION DEPTH
CITY� TEL. NO.
9 �STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. I—CbUNTY `
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ SS.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP. NO. JOB NO. a
HOUSE SEWER CONNECTING TOTRUNK PERMIT NO. ROAD PERMIT NOO
PRIVATE DISPOSAL SYSTEM @ S3.00 .
CONNECT ADDITIONAL BLDG.ORA Q AFFIDAVIT WAI ER ASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 p O
OVERFLOW SEEPAGE PIT,DRAINFIELD F
EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE 65.00 H R S W E I W
a
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00
CONNECTION CHARGE FEE CHA S
AUTHORIZATION TOTAL FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENTFE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER A
OWNERS AGENT
CONNECT ADDITIONAL (jc`
ADDRESS ,`®CPi®OR WORK 6I�j'_f ��A
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 AMWAN
LY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS COU. Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LNE OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO SCRIEN AL PR RTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE t BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
j�'L�D 2 2 9 31" ju-N 4 1 0 D 5.00-