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HomeMy Public PortalAbout4829 GLICKMAN AVE_Sewer__ R 76A642D-62 APPLICATION FOR PERMIT 76A642tll COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL U DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS /a� f JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST ` FOR APPLICANT TO FILL IN CROSS BT. LEGAL DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT /© ADDRESS F BLDG5. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO,GROUP MAP PROCESSED BY _ BK PG CONTRACTOR'a I Y ADDRESS - CONNECTION DATA CITY TEL. T I f NO. i i7� SON DEPTH - U�� r�_ COUNTY MANHOLE REFERENCE VVV UP REGISTRATION NO. _ NO. DESCRIPTION OF WORK FEE TYF LENGTH FROM HOUSE SEWER CONNECTING TO Y. 1 P.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 P.C.NO. SEPTIC TANK,SEEPAGE PIT OR MPNOJOB NO PITS AND/OR DRAINFIELD @ 510.00 CO.. . . . /y HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. �x PRIVATE DISPOSAL SYSTEM @ S3.00 U CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN.,CESSPOOL,DRYWELL.MA NH OLE @ $5.00 ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING e_6 SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT 61 21 00 CHARGES AUTHORIZATION TOTAL FEE ell CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTI G DWELLING TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF _19— OWNER 9_OWNER OR NEW HOUSE SEWERIA OWNERS AGENT_ - 4 CONNECT ADDITIONAL ADDRESS BUILDING OR WORK I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S) 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 BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT THE LEGAL OV�,CIER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE AB SCRIB�EENTI PROPERTY. gBANDON HOUSE SEWER SIGNATURE j , BACKFILLSEPTIC TANKS ❑OF PERMITTEE /�''I�/�-/� SEEP,PITS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER CK. 12"1 0 ' ' VV I' I -62 76A642D APPLICATION FOR PERMIT 6A642 �I 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 J� y� LOCALITY / G�- NEAREST FOR APPLICANT TO FILL IN CROSS BT. LEGAL DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT ADDRESS O. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS �° DISTRICT NO. GROUP MAP PROCESSED BY BK PG CONTRACTOR ADDRESS CONNECTION DATA CITYTEL. NST TION STATEMANHOLE REFERENCE / UPPER REGISTRATION NO. COUNTY _ _ ' NO. DESCRIPTION OF WORK FEE TYPECO NNE TI LENGTH FRO s,- HOUSE SEWER CONNECTING TO Y. OU .L. M.L.TO P.L. PUBLIC SEWER @ $5.00 SEPTIC TANK,SEEPAGE PIT OR P.C.NO. V PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. �✓ O Im PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR,NO. DATE WORK TO HOUSE SEWER @ $3.00 1 OVERFLOW SEEPAGE PIT, RAI NFIELD Ir EXTN.,CESSPOOL,DRYW .MANHOLE @ $5.00 ray HWY.OR ST.WIDENING .6. ALTER,REPAIR OR AL B HOUSE ..., SEWER OR DISPO T M @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNER'S PERMIT $ CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE,.� 1 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 TANK,SEEP,PIT(S) AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT 1 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 THE LEGAL OWN OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE AB E D S(:RIBED RES TIAL ROPERTY. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF TURF TE SEEP,PITS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER CI( F 9 1