HomeMy Public PortalAbout5112 GLICKMAN AVE_Sewer__ D
CE808 8.311 APPLIC ��TION FORC PERMIT
E308 7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
JOHN A. LAMBIE, CountF Ea ser ADDRESS - y l '
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. Com+
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACTMAIL Z/j� S
" ADDRESS C C sv
NO.OF BLDGi
SIZE OF LOT NOW ON LOT CITY ,Z° /4 TEL. NO. _ y
USE OF DISTRICT N0. GROUP MAP PROCESSE Y
BUILDINGS BK
CONTRACTOR P6
CONNECTIO
ADDRESS "� `� N DATA
CITY7Z S TTEL.N0. �`/l�-6�(`6 STATION 0-7Z-7�, `� DEPTH J
REGISTRATION N0. X7.5.3 �_Ty COUNTY S ATE MANHOLE REFERENCE '� `,� L0
No. DESCRIPTION OF WORK FEE
/ HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 3 GGy
YPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. 9
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -.S or, REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF19_ NEW HOUSE SEWER
OWNER OR � j� CONNECT ADDITIONAL
OWNERS AGENT_ 111 f_.j BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND ST
AITE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSALSYSTEM
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 RESIDENTI PROPE Y.LBACKFILL SEPTICTANKS ❑
SIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTEE
®� -VAI. ROBERT WOOD
CK. // M..0.o. cesy SUPERVISING MECHANICAL ENGINEER
J