HomeMy Public PortalAbout4823 GLICKMAN AVE_Sewer__ U
16A642.62
7 D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY /�
NEAREST
I
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL `
DESCRIPTION LOT NO. o� E OWNER
MAI ,'el////
BLOCK TRACT ADDRESS - l
N SLOGS. `` J
SIZE OF LOT• NOW ON LOT CITY G1�j /C�f TEL. NO.
USE OF �cd/,P�//h
BUILDINGS Gi '✓ DISTRICT NO. GROUP MAP PROCESS BY
BK PG
CONTRACTOR -
ADDRESS / � Q� `•L� CONNECTION DATA
CITY / TEL NO.�c1 STATION DEPTH
6 g _ STATE MANHOLE REFERENCE
REGISTRATION NO. / ❑ COUNTY LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CO ION LENGTH FR
HOUSE SEWER CONNECTING TO OC Y. CURB P.L. M.L.TO P.L. p� d
PUBLIC SEWER @ $5.00 ) P.C.NO. O
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. 1/ .10B NO. V
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N O
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD G.
E XTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY.OR ST.WIDENING .�yj
ALTER.REPAIR OR ABANDON HOUSE L
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS t_.PERMIT 2 00 CHARGES
AUTHORIZATION TOTAL FEE do CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN <AMED CON- REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DA Ig_
J ) ^
OWNER OR NEW HOUSE SEWER ',
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE nLEGOWR OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB E ESL'RIQIAL OF,
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.