HomeMy Public PortalAbout5011 GLICKMAN AVE_Sewer__ A
5&.E-6Dfi3 11.55 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOS Angeles BUILDAD RE s�j
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY / G
FOR APPLICANT TO.FILL IN CROSS ST.
LEGAL J, It •
D/E�SC IPTION LOT 0. ✓ OWNERMAIL
ADDRESS
j NO, OF BLDGS. !j vv CITY TEL. NO,
SIZE OF LOT NOW ON LOT T
USE OF DISTRICT NO. GROUP MAP
BUILDINGS � / + /�
�f— BK PG
CONTRACTOR '
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ADDRESS CONNECTION DATA
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_ 01 STATION 'f DEPTH
CITY �� TEL. N0 -� MANHOLE REFERENCE
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REGISTRATION NO. STATE LOWER
/ )o-- J � ❑ COUNTY
N0. DESCRIPTION OF WORK ` FEE
TYPE OF CTION LENGTH FROM
HOUSE SEWER CONNECTING TO _rl �" /7 Y. CURB a P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR —
PITS AND/OR DRAINFIELD @ $3.00 �J
OVERFLOW SEEPAGE PIT,DRAINFIELD CO, IMP. N0. ' L / JC. O
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 OB N
HOUSE SEWER CONNECTING TO /'y/
PRIVATE DISPOSAL SYSTEM @, $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. rL
fCONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 d PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPR V,L
/C RG
CON ON CHARGE FEE-
OWNER'S PERMIT $ 1 00
REIMBURSEMENT EEE
AUTHORIZATION TOTAL FEE 7 , G
1 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. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT 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 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 OF THE ABOVE - -
DESt'I'BED RESIDENTIAL PR/Qq/PP�EERTY. BACKFILL SEPTIC TANKS❑
SI / i{�� '�,jL71� - /� j/ SEEP. PITS) ❑ CESSPOOLS❑
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATI ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N. 0
ASH
f ,o 1 1 LM SEP 2 4 1 0 A 7.50