HomeMy Public PortalAbout5104 GLICKMAN AVE_Sewer__ Y
EV08 D e.sa
Cea'oa APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
�
JOHN A. LAMBIE, County En or �
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. Co ii1 C44V OWNER
BLOCK TRACT
MAIL
0-- / 'y ADDRESS -��-
(� NO.OF BLD -c;:./
SIZE OF LOT (} �°a�.�,e�® NOW ON LOT CITY Ca{Ltg{: R TEL. NO.
USE OF
BUILDINGS e�t�. :`�L-� DISTRICT NO. GROUP BK MAP PG !y/ PR WSSED
CONTRACTOR �f
ADDRESS �y CONNECTIO A T A )
CITY � TEL.N0. dp R� ' STATION DEPTH y
❑❑ STATE MANHOLE REFERENCE E
REGISTRATION NO. ❑ COUNTY ® :plyp�
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 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 TOP.C.NO. `
_ PRIVATE DISPOSAL SYSTEM @ $1.00 --® -NO. 308`�f0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
_ WORK TO HOUSE SEWER @ $1.00 +
SEWER,OR DA3POSAL SYSTEM HOUSE @ $1.00 STATE EN " CHMENT
PERMIT N0.
INDUSTRIAL
STE APPROVAL
i ARGE
OWNERS PERMIT $ 2 00 FEE
AUTHORIZATION TOTAL FEE RSR9MP &4EPFT-FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ~J
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE IN PECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _
r r)�
_ SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER ORf�` ��F�� CONNECT ADDITIONAL
OiNNERS AGENT / BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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 AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 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
DESCRIBED RESIDENTIAL P OPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE^��,t, SEEP.PIT(S) [I CESSPOOLS El
OF PERMITTEE
®° LMATION ROBERT A. WOOD A .
cK. Y.O. CASH SUPERVISING MECHANICAL ENGINEER
LAAO 9 4 7 5 v APR 1_ 9 0 A 5.0 0