HomeMy Public PortalAbout5105 GLICKMAN AVE_Sewer__ I �
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C � APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DIVISION
ADDRESS I '`U'e' -"-''• � '
JOHN A. LAMBIE, County Engineer p
CASSATT D. GRIFFIN, Supt of Building LOCALITY
FOR APPI I ANT TO FILL IN
NEAREST
LEGAL OWNER ^-a nr
DESCRIPTION LOT N0. w
MAIL PJA_
BLOCK TRACT ADDRESS
SIZE OF LOT')-JL,9'6k'' �Z NOW ON LOTS I CITY 4.A �-BSC-t'.'.---'�-- TEL. NO.
USE OF ((��
BUILDINGS RSLJ4Ac1.�-r. DISTRICT NO. GROUP MAP PROCESSED:IIY
BK PG /
CONTRACTOR `
ADDRESS �'� CONNECTION DAA 4J
CITY y � TEL.NO. 6 l� t1 fkG. STATION L DEPTH
p, p 5 ❑ STATE MANHOLE REFS ENCEg l�/ +1 E
REGISTRATION NO.B{� 'y, ❑ COUNTY cJ� W. V
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER Co) $3.00 Crf� TYPE OF CONNECTION LENGTH FRO
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.
TO P.L.
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PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. -1
PRIVATE DISPOSAL SYSTEM @ $1.00 oCD_jjm_Nff- JA8�f9.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00 •
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
GES
OWNERS PERMIT g 2 00 s
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROV -I.S DATE INSPECT 'S SI ATU
TO THE PUBLIC SEWER. _
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 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 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 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED REST ENTIAL PROPERTY. r� Iy BACKFILL SEPTIC TANKS ❑
SIGNATURE i��+�` SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
OF VALIDATION ROBERT A. WOOD
CK. H.0. CASH SUPERVISING MECHANICAL, ENGINEER
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