HomeMy Public PortalAbout4825 GLICKMAN AVE_Sewer__ CEl1011
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76A642D 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, Supt of Building !!El
LOCALITYNEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL DESCRIPTION LOT NO. OWNERMAIL
BLOCK �TRACT /O ADDRESS
LNO. OF BDGS.SIZE OF LOT NOW ON LOT CITY TEL.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP OCESSED BY
BK
PG
CONTRACTOR
ADDRESS d �$� CONNECTION DATA
i/
CITY TEL. NO. STATION DEPTH
a/i`"
/ �� TATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. f}
PUBLIC SEWER @ $5.00 v
P.C.NO. U
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. JOB NO,
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUN E OIT�NOC
PRIVATE DISPOSAL SYSTEM @ S3.00 he V
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER E SEMENT RECORD. NSTR.NO. DATE
WORK TO HOUSE SEWER 53.00
OVERFLOW SEEPAGE PIT,DRAINFIELD _ h
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS I PERMIT $1 2 Oo - -
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC AND/OR DRAINFIELD
TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY 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 I THE LEGAL O ER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO D SCRIBED ES TI ROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
C M,O. CASH