HomeMy Public PortalAbout5447 HILTON AVE_Sewer__ ""°°'°
9-SB APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILD" F
WM.J. FOX, COUNTY ENGINEER. ADDRESS
CABSATT D. GRIFFIN. SUP'T of BUILOING LOCALITY O
M�j
�J FOR APPLICANT TO FILL IN CFO55 ST. i✓r l,tJ //�t..V-?/
DESCRIPLEGLTION LOT NO. / D OWNER
BLOCK TRACT MAIL
ADDRESS
NOOF BLDG .
SIZE OF LOT J0iI BYi B NOl ON LOTS CITY TEL. NO. t. Q10;r
USE OF
BUILDINGS,., ` / DISTRICT NO. GRO/UUPP 61AP
EK
C ACT R � O(� r' 5 cY G IDPG
ADDRESS 4 }, Ir �.�y CONNfE,CTION DATA
CITYj TEL. NO. 2 6� Dr STATION J ./, 0 DEPTH O
Al
❑ STATE MANHOLE REFERENCE° �7 I� q UPPER
REGISTRATION NO. C1 COUNTY /_, d L9YIfa
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTIq;k- � LENGTH FROM /
PUBLIC SEWER T� $ 3.50 _� Q Y' CURB ( P L/ M L TO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR 4 D/ P. C. NO.
WORK TO HOUSE SEWER 1.00 NO. JOB NO.
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 GRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHAR S
PERMIT CONNECTION CHARGE FEE
OWNER'S S o0
AUTHORIZATION TOTAL FEE 50 REIMBURSEMENT FEE
I HAVE DATECN-
TRACTORTTOS CONNECT THEAABOVE DESCRIBEDWITH THEH EREIEXISTINGA MED DWELLING APPROVALS DATE INSPECTOR'S SIGN URE
TO THE PUBLIC BE R
NEW HOUSE SEWER
SIGNED THIS DAY OF zit 19,�
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT I BUILDING OR WORK
ADDRESS___q:2 '� •-•k /A•I �A SEPTIC TANK. SEEP, PITS)
AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A PLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/CR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
e SEEP. PIT(s) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION R. A. WOOD, CHIEF PLEIG. INSPECTOR
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