HomeMy Public PortalAbout4851 GLICKMAN AVE_Sewer__ t �I
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CEnoe-e-sa APPLICATION FOR PE MIT 1
caCOUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS Ave.
JOHN A. I.AMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY City
FOR APPLICANT TO FILL IN CROSS ST. Lower Azusa
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK A TRACT 10992 ADRESS1 O5 Vista Ave.
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT 3 1 CITYqiprrq MadreTEL.N0.
USE OF
BUILDINGS ReS , DISTRICT N0. ROUP MAP PR ESS D BY
CONTRACTOR J PG
square Deal Sewer Service , (� .Y
ADDRESS 2 Maxs on Rd. CONNECTION DATA
�f7
CI TEL.N0. STATION DEPTH
STATE MANHOLE REFERENCEUPPER
REGISTRATION NO. a COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF 50NNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
1 WORK TO HOUSE BLDG.OR G $1.00 1 QQ TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
-CHARGES
OWNER'S PERM $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 3 1 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS-------DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
NEVI SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER F THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
0 !' SEEP.PIT(S) CESSPOOLS❑
OF PERMITTE
VALIDATION ROBERT A.WOOD
�6 U.p, QgR SUPERVISING MECHANICAL ENGINEER 0