HomeMy Public PortalAbout4835 GLICKMAN AVE_Sewer__ D
S&E-669 I1-SS APPLICATION FOR PERMIT 1
3&E•6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESSIf �
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY��0•�7 .i - ��
FOR APPLICANT TO FILL IN CROSS ST. �--
LEGAL
DESCRIPTION LOT NO. OWNER 4!5 , � r• y�Ay/q
MAIL
BLOCK TRACT Yd ADDRESS
NO. OF BLDGS. CITY !!57
SIZE
TEL. NO.
SIZE OF LOT NOW ON LOT / / /y
USE OF
BUILDINGS {�• ! / -w i' DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR �/,�,�,.�r' r •
ADDRESS �/' '•' CONNECTION DATA
CITY .� TEL. NO�fSTATION 7. DEPTH
��j MANHOLE REFERENCE � UPPER
TATE
REGISTRATION NO. �j ❑ COUNTY
No. DESCRIPTION OF WORK FEE
I'
HOUSE SEWER CONNECTING TO , Y. TYPE OF CTION LENGTH FROM
URB P.L. M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
EX T N.,C E S S PO O L,D R Y W E L L,M A N H O L E@ $2.00 CO. IMP. NO. J JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.�&] 7
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AHAVE AT THIS DATE A REIMBURSEMENT FEE
UTHORIZATION TOTAL FEE
I CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER 7-
SIGNED THIS DAY OF _19 CONNECT ADDITIONAL
OWNER OR , r BUILDING OR WORK
OWNERS AGENT �/� _,(� , SEPTIC TANK,SEEP, PIT(S)
LDRES AND/OR DRAINFIELD
EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYLL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
NG AND SEWERS. SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORDISCONNECT PLUG AND
ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFRNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE BANDON HOUSE SEWER
ED RESIDENTIAL PERTY. BACKFILL SEPTIC TANKSURE _SEEP.PIT(S) ❑ CESSPOOLS❑RMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. 0. CASH
X14 4 .5 M