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Home My Public Portal About4859 GLICKMAN AVE_Sewer__ CE808 10-63 76A642D - APPLICATION FOR PERMIT A64 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, Supt of Building LOCALITY 7-- NEAREST FOR APPLICANT TO FILL IN CROSS BT LEGAL — - — - DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT Q ADDRESS NO. OF BLD S. SIZE. OF LOT NOW ON LOT CITY G,. TEL. NO. USE OF DISTRICT NO.1 GROUPI MAP PROCESSED BY BUILDINGS BK PG J CONTRACTO / • • �/ ./ ADDRESS3 + yQ -`I CONNECTION DATA CITY TETATI ON/iy DEPTH zoo J� (� El STATE MANHOLE REFERENCE REGISTRATION NO. �V J ❑ COUNTY . LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONN C LENGTH FROM HOUSE SEWER CONNECTING TO Y. C P,L. M.L.TO P.L. PUBLIC SEWER @ $5.00 C P.G.NO. SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. O PITS AND/OR DRAINFIELD @ E10.00 U HOUSE SEWER CONNECTING TO TRUNK PERMIT NO.• ROAD PERMIT R/��'�, PRIVATE DISPOSAL SYSTEM @ $3.00 L O CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER ERIEMENI RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD LU __.___ EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $6.00 re% - D_' ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT _.. PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT s z o0 CHARGES AUTHORIZATION 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 OL 19_ -, OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PITS) I HEREBY ACKNOWLEDGE THAT 1 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 ❑ 1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLE COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL O NER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, ABOVE SC ED ESI ENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATU BACKFILL SEPTIC TANKS ❑ OF PER EE DE - SEEP.PITS) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD CK. w. o. cnsH SUPERVISING MECHANICAL ENGINEER ' V - 0-63 76A642D APPLICATION FOR PERMIT 6A642 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FADDRE G JOHN A. LAMBIE, County Engineer S WILLIAM A. JENSEN, Sup't of Building YTFOR APPLICANT TO FILL IN SLEGALDESCRIP ION LOT NO.BLOCK TRACT Q S NO. OF SLOGS. T / SIZE OF LOT NOW ON LOT CITY / ` . TEL. NO. USE OF DISTRICT NO. GROUP MAP P GESSED BY BUILDINGS BK S/PG CONTRACTO r E V �•^ J.� [J r / ADDRESS CONNECTION DATA it STATION DEPTH CITY TEL. STATE ,e+ P REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE } [ LOWER NO. 1 DESCRIPTION OF WORK FEETYPE CONN C LENGTH FROM HOUSE SEWER CONNECTING TO Y. F P.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 P.C.NO. CL SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. O PITS AND/OR DRAINFIELD 510.00V HOUSE SEWER CONNECTING TO TRUNK PERMIT N0. ROAD PERMIT ix PRIVATE DISPOSAL SYSTEM @ $3.00 (((/// 0 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEE [ASEMLNT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELDCIL LLJ EXT N.,CESSPOOL,DRYWELL,MAN HOLE @ $5.00 4 „ - h ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING �� Z SEWER OR DISPO S SYSTEM $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL L j1 WASTE APPROVAL OWNER'S PERMIT a CHA GES AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE 'I HAVE AT THIS DATE A CONTRACT WIT THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESkflRIBED EXISTING DWELLING APPROVALS .w TO THE PUBLIC SEWER. DATE - I ECTO R'S SIGNATURE SIGNED THIS DAY OF�y�'777 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 ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR .� LICENSED AS REOUI D BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR T I- M THE LE OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, T OVE ESCRI ES ENT L PROPERTY. ABANDON HOUSE SEWER SIGNATURE J**_ BACKFILL SEPTIC TANKS ❑ OF PERMIT 0-1 -- SEEP,PIT IS) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD SUPERVISING MECHANICAL ENGINEER CK, M.O. CASH I