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HomeMy Public PortalAbout5001 GLICKMAN AVE_Sewer__ 24650 INSERTS � f' 768098.60 76A6427 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION ADDRE NG r©� y ADDRESS .7 ! (✓ ineer WILLIAM A.JJENSEN, Supt ofuBuilding LOCALITY r NEAREST FOR APPLICANT TO FILL IN CROSS ST. > LEGAL DESCRIPTION LOT NO. �� !� OWNER ' BLOCK TRACT MAIL P� ADDRESS NO.OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE BUILDINGS' PG BK DISTRICT NO. GROUP I MAP I PROCESSED BY • CONTRACTOR ADDRES v CONNECTION DATA CITY TEL.NO. STATION DEPTH ❑ TATE MANHOLE REFS ENCUPPER REGISTRATION N0. Y�7 C, ❑ COUNTY LOWER NO. DESCRIPTION OF ORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 OF CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. . CURB P.L. M.L.TO P.L. PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL.DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO P.C. . PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. OAD PERMI O WORK TO HOUSE SEWER @ $1.00 > V ALTER,REPAIR DISPOR OSAL SYSTEM HOUSE @ $1 00 'STATE ENCROACHMENT PERMIT NO. p INDUSTRIALV WASTE APPRO W CHARGES M OWNERS PERMIT $ 200 TRACTOR TO CCONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE I/ REIMBURSEMENT FEE I HAVE AT IS DATE A CONTRACT WITH THE ONNECT THE ABOVE DESCRIBED EXIISTIING DWELLNAMED ING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. r SIGNED THIS DAY OF 19_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT1 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 A SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPER REGISTERED AND/OR DISCONNECT PLUG AND LICENSE S REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFOR OR THAT 1 AM T LEGA OWNER OF THE ABOVE DESCRI JOWIDENTIAL PROPSAA BACKFILL SEPTIC TANKS ❑ SIGNAT R e SEEP.PIT(S) ❑ CESSPOOLS ❑ OF PERMITTE ®P VALIDATIOI , ROBERT A. WOOD crL 11.0. cnsH SUPERVISING MECHANICAL. ENGINEER