HomeMy Public PortalAbout5005 GLICKMAN AVE_Sewer__ D
S&E-663 12.54 APPLICATION FOR PERMIT 1
5&E•6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING C r
WM.J. FOX, COUNTY ENGINEER ADDRESS .7
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO L IN NEAREST
EGA
CROSS ST.
L17-91:7Qb�T
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SCR 4
SCRI �
OWNER �r
BLOCK TRA C I 0 �'A ADDRESS �f.
n �/ NO. OF BLDGS, h�
SIZE OF LOT /v//� NOW ON LOT �" CITY EL. NO.
USE OF 0—A
BUILDINGS : '~ DISTRICT NO. GROUP MAP
CONTRACTOR T _ I BK
ADDRESSCONNECTION DATA
CITY TEL. NO. ,,L STATION / 7, Cl DEPTH fell '
❑ STA MANHOLE REFERENCE 2 I'
REGISTRATION N0. �� `7 '7. /Y6'/LOWER �
TYPE OF-7CrDthli�CT10N LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB i P.L. M.L.TO P.L. , r
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ r 3.50 ti� 0
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP.NO, / JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. s�
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL _
SPECIAL CONDITIONS ONLY 2.00 CHARGES
-- CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE ,ELLIINGV REIMBURSEMENT FEE 1
TRACTORHAVE TOS CONNECTLATE O NTRTHEA CTEABODVE WITH DESCRIBED EXIISTINGTHE HEREIN p DWMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC 5
SIGNED THIS DAY OF v 9� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT a BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY C Y THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A$ TIEO RED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA' OR T AT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE TIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE -.•� ,,.+ .'
SEEP.PITS) ❑ CESSPOOLS❑
OF PERM ITT E - - ;1
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY ., Co eY 652t—) JAN 9 4 550
a
DEPUTY DEPUTY
BY BY
® DEPUTY r DEPU�