HomeMy Public PortalAbout4832 GLICKMAN AVE_Sewer__ yIF-3 �-
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76AAPPLICATION FOR PERMIT
78A 84 -� �/;.
COUNTY OF LOS ANGELES SEWER-SE �AGE ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building —
Locnurr c
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. �. OWNER
— MAIL /
BLOCK TRACT f ADDRESS J
NO. OF/F31-06S.
SIZE OF LOT NOW ON LOT .5 CITY L. NO.
USE OF // DISTRICT NO. ROUP MAP PROCESS r Y
BUILDINGS /
BK PG
CONTRACTOR S
ADDRESS V CONNECTION 15ATA
CIT T.L. N04r4< 17� STATION DEPTH
STATE MANHOLREFERENCE PE
REGISTRATION NO. / Q COUNTY E
NO. DESCRIPTION OF WORK FEETYPE OFC TION LE TH FROM
HOUSE SEWER CONNECTING TO Y. CUR - P.L. M.L.TO P.L.
PUBLIC SEWER 55.00 P.C.NO. U
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO.
PITS AND/OR DRAINFIELD $tO.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ 83.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYW ELL,MANHOLE $5.00
HWY.OR ST.WIDENING
SEWER 04O"4
/ ALTER, HOUSE --
H +GGi4.SYSTEM $3.00 STATE ENCROACHMENT
E PERMIT NO.
INDUSTRIAL
A WASTE APPROVAL
CHARGES
OWNEWS PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT T ABOVE DESCR G EXISTING DWELLING
TO THE PUBLICSE APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY O 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECTADDITIONAL
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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERL TIERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES, O TY NO STATE OF SEWAGE-DISPOSAL SYSTB'M �-
CALIFORNIA OR THAT I HE LEGAL O F. A INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ASO V DE RIBED N AL P RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS 13OF PERMITTEE SEEP,PIT(s) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
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