HomeMy Public PortalAbout5525 HILTON AVE_Sewer__ S - D
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APPLICATION FOR PERMIT
1
aNDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING / .r.� ti A!Y/C
JOHN A. LAMBIE, COUNTY ENGINEER DRESS
AD __JJ ,/ y
® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY [G Ni hF
FOR APPLICANT TO FILL IN CROSSLEGAL
ST. ILO vI
DESCRIPTION LOT NO. /7 OWNER _ f—tSS I-/�-j'
BLOCK TRACT //�� /��/U MAIL
ADDRESS 552,'J /`/ Q 10
SIZE OF LOT�K /V NOW ON LOTOF S / CITY �/yl L 1/ TEL. N0. r 74 7 D
USE OF DISTRICT NO. GROUP MAP
B UILOINGS 6_ J
BK PG
CONTRACTOR �q Iw A /
ADDRESS 4' YV G CONNECTION DATA
STATION IF., O DEPTH /
CITY TEL. NO.
MANHOLE REFERENCE PE
El STATE
REGISTRATION NO. - LJ COUNTY v
NO. DESCRIPTION OF WORK FEE ��
TYPE 0 TION LENGTHFROM
HOUSE SEWER CONNECTING TO o Y. CURB P.L. M.L. TO P.L.
PUBLIC SEWER @ S 3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD Q $3.00 h
OVERFLOW SEEPAGE PIT.DRAINFIELD lOB N0O
EXTN.,CESSPOOL,DRYWELL.MAN HOLE Q $2.00
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q S 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE C/K REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DFYWELL❑
AND STATE THAT THE ABOVE 15 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 AND
DISCONNECT PLUG
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGD
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER --XALIDATION ROBERT A. WOOD. CHIEF PL5G. INSPECTOR
CASH
LJCO2332�- MAR24 4 A 4.50 m