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Home My Public Portal About4836 GLICKMAN AVE_Sewer__ tD_62 76A642D APPLICATION FOR PERMI 78A84 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS C. WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO. 15 OWNER MAIL BLOCK TRACT ADDRESS O. OF BLDGS. SIZE OF LOT NOW ON LOT ��J CITY TEL. NO. USE OF BUILDINGS / %� DISTRICT NO. GROUP MAP PROCESSED BY �j BK PG CONTRACTOR ' �i �•® �v. ADDRESS + /LO c CONNECTION DATA S AT ON s_ DEPTH CITY , TEL. NOI� /7 TATE UP Q/y MANHOLE REFERENCE REGISTRATION NO. 5�_ ff7 COUNTY 11) / NO. DESCRIPTION OF WORK FEE TYPE F �FT101J LENGTHP. OM HOUSE SEWER CONNECTING TO _ R // P.L. M.L.TO _ O V SEPTIC TANK,SEEPAGE PIT OR PUBLIC SEWER @ $5.00 P.C.NO. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. 09 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD V� EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 Z ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL YSTEM @ $3.00 STATE ENCROACHMENT _\ PERMIT NO. l INDUSTRIAL } /� WASTE APPROVAL OWNERS PERMIT $ CHARGES AUTHORIZATION TOTAL FEE ! CONNECTION CHARGE FEE LANA VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING HE PUBLIC SEWER. APPROVALS 1;ATE INSPECTOR'S SIGNATURE ED THIS DAY OF 19_ ER OR NEW HOUSE SEWER ERS AGENT CONNECT ADDITIONAL _ BUILDING OR WORK ESS SEPTIC TANK,SEEP,PIT(S) EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ALL COUNTY ORDINANCES AND STATE LAWS REGULATING BING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ EREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR NSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM FORNIA OR THAT M THE LEGAL O R AND INTEND TO DISCONNECT PLUG AND E IN, THE AB E ESCRI BEq�R NTIA R OOPERT Y. ABANDON HOUSE SEWER ATURE �/ L�L'rZi'Ltl. BACKFILL SEPTIC TANKSPERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ cc, ALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER M.O. CASH °'62 7GA642D APPLICATION FOR PERMI 76A 842 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS f WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN `ROSS ST LEGAL DESCRIPTION LOT NO. ` OWNER MAIL BLOCK TRACT ADDRESS N6. 6FBLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GRO MAP PROCES�BY /(JF BK PG CONTRACTOR ADDRESS j.. 0-.� f ` CONNECTION DATA >/ S ON DEPTH ,�-- CITY / TEL. NO. REGISTRATION NO. ' ��`-'� COUNTY MANHOLE REFERENCE IIoPER _, NO. DESCRIPTION OF WORK FEE TYPE C N IOIi LENGTH F M HOUSE SEWER CONNECTING TO Y L P.L. M.L.TO P. PUBLIC SEWER @ $5.00 O P.C.NO. SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 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 /y WASTE APPROVAL !!// OWNERS PERMIT $ 2 00 CHARGES AUTHORIZATION I TOTAL FEE G CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNE BO VE DESCRIBED EXISTING DWELLING TO THE PUBLIC SE ER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DA 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PIT(5) 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 ❑ 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 M THE LEGAL OW F, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO ESCRIBED R NTI"PROPERTY. ABANDON HOUSE SEWER SIGNATURE BgCK FILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VM.O. CASH ALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK. � 1