HomeMy Public PortalAbout5470 HILTON AVE_Sewer__ 24650 INSERTS
C5e0e6.90 APPLICATION FOR PERMIT
'8Ae°�° COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADORESSG 7 !L b 'Apr
TORN A. LABIE. County Engineer
WM
ILLIAM A. JENSEN, Sup'1 of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL OWNER
DESCRIPTION LOT NO. -
BLOCK TRACT AMAIL /mob
ODR ESS . fJ'
NltOF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROU MAP PR CyES/S/ESD BY
CONTRACTOR r :f, O/U„ A
ADDRESSkls 6-
CAAAO""N"JJJNECTIOLN ATA l 17/A
CITY 1j� TEL.NO./, Gyi/.�o J STATION L3� � r DEPTH
STATE
REGISTRATION NO.
�� / / y e COUNTY MANHOLE REFERENCE /
NO. DESCRIPTION WORK FEE
HOUSE SEWER CONNECTING TO `�
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROM
PITS AND/OR URAINFIELDIT OR @ $3.00 SEPTIC TANK.SEEPAGE Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00 P C NO 0
HOUSE SEWER CONNECTING TO CO.IMP. N0. JOB N0,
PRIVATE DISPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. p
U
SEWER REPAIR
R nlSPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT 1d
PERMIT NO, O
INDUSTRIAL
WASTE APPROVAL W
CHARGES N
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE 4
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS /DATE/ INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. I
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL f
OWNERS AGENT z I BUILDING OR WORK I -
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT ROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP. PIT(') ❑ CESSPOOLS ❑
OF PERMITTEE -.
®r VALIDATION ROBERT A. WOOD
Ci M.0. : SUPERVISING MECHANICAL ENGINEER
Ij"�"o0406 —� JULP11 0 5.00