HomeMy Public PortalAbout5518 HILTON AVE_Sewer__ 9 - APPLICATION FOR PERMIT 1
SaE66DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depambnont of County 4 glneer I �I!
County of Los An ales BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® - CASSATT D. GRIFFIN, SUPT OF BUa D1Nc LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.LEGAL
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DESCRIPTION LOT NO. OWNER r //n/F�/'�ef� /'n �(_ k I/�/Y Gy
MAIL
BLOCK TRACT , a (�/ Q ADDRESS
/ N0.OF SLOSS
.
SIZE OF LOT SX/ O NOW ON LOT CITYI ./A/��•J L' �)! / TEL. NO.
USE OF
BUILDINGS A DISTRI✓^'f`CT Nq. GROUP MAP
CONTRACTOR
ADDRESS eJ 9� I CONNECTION DATA
i Jo nn A J
CITY EL. dO. STATION DEPTH
MANHOLE REFERENCE UPPER
STATE _ O LO ER
17
REGISTRATION 10. d ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOY CURB TYPE OF CTION LENGTH FROM
PUBLIC SEWER @ P.L. M.L. TO P.L. dJa
SEPTIC TANK,SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD @ $3.009
OVERFLOW SEEPAGE PIT.DRAINFIELD CO, IMP. NO. c„ )OB N O
EXTN.,CESSPOOL,DRYWELL,M AN HOLE �� $2.00
HOUSE SEWER CONNECTING TO J
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT N0, e•/
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ S 1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE pa
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSP .S 5le ATURE
TRACTOR TO CONNECT T E ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE/1 6 ...{_ NEW HOUSE SEWER
SIGNED THIS DAY.OF 19SV
A/ CONNECT ADDITIONAL
OWNER OR/, I�t / �. �� BUILDING OR WORK
OWNERS p •iYl/1 lT/v"v" v ! Com' '.>,��L-YI[!.!_/
SEPTIC TANK,SEEP,PIT(S)
ADDRESS • r '"al / nA_P� Iw/Y/I/J�rL. : �2. �/ ANO/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND 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 HO PLUGAUSE D
CALIFORNIA SI THAT IjM THE LEGAL-OWNER OF THE' VE BACKFILL SEPTIC TANKS❑
ER
DESCRIBED RESIDENTIAL PROPERr/
SIGNATURE / L I U� SEEP. PIT($) ❑ CESSPOOLS
OF PERMITTEE (� wwn��i
JOHN A. LAMBIE, COUNTY IENGINEER CK. VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
Lo 5 CASH 9 OCT 14 1 0 A 5.0 0 M