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Home My Public Portal About4846 GLICKMAN AVE_Sewer__ 0-63 766A642D APPLICATION FOR PERMI aig2L! 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 LOCALITY NEAREST FOR APPLICANT TO FILL IN `ROSS ST. LEGAL - _ --- DESCRIPTIO LOT NO. OWNER MAIL BLOCK TRACT ADORE.' O. OF D SIZE OF LOT NOW ON LOT CITY s TEL. NO ` &11 USE OF BUILDINGS DISTRICT NO. GROUP MAP P-BQC ESSED BY BK PG 1/ J\ CONTRACTOR/ ADDRESS ,UC.�. ' CONNECTION DATA /' S ATION .(� DEPTH C. CITY ""'TEL, TATE MANHOLE REFERENCE L�- REGISTRATION NO. G//'/ !L� COUNTY �Z LOWER El NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONN CT LENGTH FROM HOUSE SEWER CONNECTING TO `� Y. C P.L.+ M.L.TO P.L. PUBLIC SEWER @ $5.00 P.C.NO. a SEPTIC TANK,SEEPAGE PIT OR JOB NO. PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO. O N HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO./ J0 PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIV[R I EASEMENT RECORD,INSTR,NO. DATE O WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD W EXT N.,C ESSPOOL,DRYWEL L.MA NHOLE @ $5.00 a ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING N SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z I PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2 Oo AUTHORIZATION TOTAL FEE +� CONNECTION CHARGE FEE CHARGES l�9 'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED S 'S[ATURE LITING DWELLING APPROVALSTOTHE PUBLICSEWER. DATE INSPECTOR SIGNED THIS D Y F 19 OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PIT(5) I 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 ElDRYWELL (_1 I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DOR ALTER,REPAIR,SEWER OR LICENSED AS REOU BY LOS ANGLES T' AND ST TE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR AT I M THE LEGAL E F, AND I END TO DISCONNECT PLUG AND RESIDE IN, T ABOV DESCRIBED R AL OPE Y. ABANDON HOUSE SEWER SIGNATURE ACKFI L SEPTIC TANKS ❑ OF PERMI _ SEEP. PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD l�� SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH L_L0 5 6 2 2.n NOV 5 1 D 7.00- J CE808 10-63 76A542D APPLICATION FOR PERMIT I COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS qJw WILLIAM A. JENSEN, Sup't of BuildingLOCALITYNEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL DESCRIPTION LOT NO. OWNERMAIL TRACT ADDRESSNO. OF LDGS. /SIZE OF LOT NOW ON LOT CITYUSE OF DISTRICT NO. GROUP MAP BUILDINGS ��st� BK PGCONTRAC �.. � �� ADDRESS CONNECTION DATA ST ION DEPTH CITY TEL TATE REGISTRATION NO. MANHOLE REFERENCE ❑ COUNTY NO. DESCRIPTION OF WORK FEE TYPCONN T LENGTH FROM HOUSE SEWER CONNECTING TO Y. C ,�°PA.. M.L.TO P.L. _J d PUBLIC SEWER @ $5.00 P.G.NO. O SEPTIC TANK,SEEPAGE PIT OR JOB NO. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 (J OVERFLOW SEEPAGE PIT,DRAINFIELD W EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 O. H ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER&LpiMSPO SAL SYS M @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL v) CHARGES OWNERS PERMIT $ AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE -I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR 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 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 ATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT i AM HE LEGAL OWNER OF, AND IN END TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE S RIBED REBID IAL PR ER ABANDON HOUSE SEWER SIGNATURE + BACKFILL SEPTIC TANKS ❑ OF PERMITTEE PITIS) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH V:� 5 6 2 3-11-a' NOV 5 1 1 A 42: 5.C) 0"