HomeMy Public PortalAbout4828 GLICKMAN AVE_Sewer__ 76A64 10.82 APPLICATION FO PERMIT
76A842D
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 C
LOCALITY
NEAREST /
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /
DESCRIPTION LOT NO. OWNER
r MAIL
BLOCK TRACT _ ® �--� c ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
I BK PG
CONTRACTOR J .—.{� /J✓J
ADDRESS A CONNECTION DATA
�76Gl STATION , DEPTH
CITY TEL. NO. /
ElSTATE UPPER }
REGISTRATION NO. /L• El COUNTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF NNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TO P.L. (�
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 IM /O. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (,J
PRIVATE DISPOSAL SYSTEM @ $3.00 1L
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR. DATE
WORK TO HOUSE SEWER @ $3.00 y
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER"S PERMIT $ z 00 CHARGES
ONNECTION CHARG EE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMEN FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. / APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS D �--� 19
OWNER OR � / NEW HOUSE SEWER
OWNERS AGEN7��l�� »�1^— CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S) `
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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 OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM T AL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A E IBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE / BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(5) ❑ CESSPOOLS ❑
i
rLIDATION ROBERT A. WOOD
M.0. CASH SUPERVISING MECHANICAL ENGINEER
L) I�o 5 3 0 9 QSS FEB 6 1 0 D 5.0 0
r
v
` AOR t0.82
78At)42D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGF, DISPOS L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNE
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS,
SIZE OF LOT NOW ON LOT CIT TEL. NO.
USE OF DISTRICT NO. GROUP ' MAP Wy
BUILDINGS
BK PG
n
CONTRACT D —
ADDRESS CONNECTION DATA
CITY A TEL. NO. ' � STATION � DEPTH
El STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. El COUNTY
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM a
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. O
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR r P.C.NO. V
PITS AND/OR DRAINFIELD @ S10.00
MP.NO. N
HOUSE SEWER CONNECTING TO Uzz�q _Rt O. O
PRIVATE DISPOSAL SYSTEM @ S3.00 F
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT AIVER EASEMENT RECORD.INSTR.NO. DA'FE W
WORK TO HOUSE SEWER @ $3.00 d
OVERFLOW SEEPAGE PIT,DRAINFIELD N
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 Z
l j_T.ER-B,F.BA4R-BR'ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR-ML9 DZA SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION I TOTAL FEE ! O-D CONNECTION CHARGE 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
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
IH
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 ❑
1 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 I AM THE LEGAL NER OF, AND INTEND TO DISCONNECT PLUG AND
:'`
RESIDE IN, THE ABO DESCRIBED 51 NTI PRO ERTY. AB�Aj F)PJh6HOUSE SEWER �;: r-' ��^.•+
SIGNATURE
OF PERMITTEE �/L!. Pi BACKFILL SEPTIC TANKS ❑ - 4'
SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M.O. CASH ck
LACC) 4 0 2 5 JAM 2 1 0 D 5.0� 0