HomeMy Public PortalAbout4843 GLICKMAN AVE_Sewer__ 7 0-63
76A6420-63
APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F..
ING ; /(
SS 1' -'`�
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building ITY A4 ?
ST
FOR APPLICANT TO FILL IN ST.
LEGAL OWNER
DESCRIPTION LOT NO.
• MAIL
BLOCK TRACT ADDRESS
1
NO. OF SLOGS. rte,
SIZE OF LOT NOW ON LOT ,,,F CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDI NGS - BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
7 �„✓ STATION DEPTH
CITY 0 TEL. NO. 1f t.' „�. UPPER
® STATE MANHOLE REFERENCE
REGISTRATION NO. - COUNTY LOWER a
NO. DESCRIPTION OF WOR FEE TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. V
PUBLIC SEWER 53.00 P.C.NO. {IA
SEPTIC TANK,SEEPAGE PIT OR CO.IMP,NO. JOB NO. J
PITS AND/OR DRAINFIELD 510.00 y,.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 >-
CONNECT ADDITIONAL BLDG.OR Fz AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CES SPOOL,DRYWELL,MANHOLE® $'5.00 HWY.OR STi WIDEffMG � O
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT -
PERMIT NO. (—
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E 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 THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19
OWNEROR NEW HOUSE SEWER
OWNERS AGENT ._.� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY 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 CESSPOOL ❑ DRYWELL ❑
PLUMBING AND SEWERS.
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 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE. DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE r @^;.(, BACKFILL SEPTIC TANKS ❑
OF PERMITTEE - a SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH