HomeMy Public PortalAbout5038 GLICKMAN AVE_Sewer__ D
CE808 APPLICATION FOR PERMIT
canoe a-sa COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADD,
DDBUILD RE1 SS N G
OHN
IE
CountEn
ineer
CASSATTAD.GRIFFIN, Sup i of Building17
LOCALITY t�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.LEAL
_DESCRI7
PTION LOT NO. / / L7 OWNER f" S�
BLOCK TRACT `� ! MAIL fir.
ADDRESS G -16 A C.
NO.OF BL•DGS. 7
SIZE OF LOT NOW ON LOT CITY TEL. NO. '!
USE OF
BUILDINGS DISTRICT N0. GROUP MAP EP :SSED�
BK PG
CONTRACTOR ei2 c'_
ADDRESS JotCONNECTION DATA
CIT 6, Q�Q / TIONI'Z L _ DEPTH
T N0. ,c J
REGISTRATION NO. �� `-` � STATE MANHOLE REFERENCE //' q
/ ER
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 v TYPE 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.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. �_ JOB NO.
CONNECT ADDITIONAL BLDG.OR "— r✓ - --�-.F.
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. RAD PE [ ,
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2_00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE G' REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSP�,,CTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
LDESCRIBED
SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
NG AND SEWERS. SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
NIA OR THAT 1 AM TH LEGAL OWNER OF THE ABOVE
BED RESIDENT PROF BACKFILL SEPTIC TANKS ❑SEEP.PIT(S) ❑ CESSPOOLSURE RMITTE
OF -"aJALIDATION ROBERT A. WOOD
CK.` Y.o. CASH SUPERVISING MECHANICAL ENGINEER
I }6(,o 7 9 3 7 FiAR 1 8 1 0 A 5.00