HomeMy Public PortalAbout5113 GLICKMAN AVE_Sewer__ 76A 642D-CE808-10-71 APPLICATI FOR P IdI1T
Cfl
OUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
15 ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRo55 ST.
LEGAL _ �q n
DESCRIPTION LOT NO. ( OWNER --3�� V
MAIL
BLOCK TRACT ADDRESS F v, qJ
SIZE OF LOT ;O WOON LOTS CITY � ' vL.
�
CiTEL.
USE OF DISTRICT NO. GROUP MAP PROC SED BY
BUILDINGS
y� BK PS
CONTRACTOR q� ,0
y CONNECTION DATA
ADDRESS
CITY TEL. NO. STATION DEPTH
STATE LIC MANHOLE REFERENCE
LICENSE NO.. CLASS C__ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LEN H FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AN0/OR DRAINFIELD @ 810.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. CL
0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEN EASEMENT RECORD.INSTR,NO, DATE 0
WORK TO HOUSE SEWER @ $3.0000
OVERFLOW SEEPAGE PIT.DRAINFIELD Q�
EXTN..CESSPOOL.DRYWELL, @ SS.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING F,
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE@ $7.00 PERMIT NO, D_INDUSTRIAL NZ
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 3 Oo
AUTHORIZATION TOTAL FEE e O/f CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. �p T APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGE
CONNECT ADDITIONAL v�
BUILDING OR WORK L}'
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
L
MBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
IDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSESEWER
NATURE BACKFILLSEPTIC TANKS ❑F PERMTTTEE ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION CK. M.0. CASH
{ 2 5 2 273 JUL 7 1 1 0 D 6.0 G'
D
CE808 APPLICATION FOR PERMIT
seoe e.sa COUNTY OF LOS ANGELES �.
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING6j�� /
JOHN A. LAMBIE,
'L
Engineer ADDRESS s(J t 11eS`t1Li
CASSATT D. GRIFFIN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN NEAREST , S%
CROSS ST.
LEGAL f
DESCRIPTION LOT N0, OWNER '/. 5 4'vj
BLOCK TRACT R MAIL }J
GC✓ ' / ADDRESS �u 3 i , S C> /llfi���
r
SIZE OF LOT ` NOW ON LOT / CITY C>6 IIA TEL. NO.,"1'2 C: r
USE OF
BUILDINGS c��t �%� DISTRICT NO. GROUP MAPeZPROq9SS:EDY/t iU �KPG CONTRACTOR ADDRESS 0 ,j'`9
CITY �3� TEL.NO. - STATION 0 DEPTH
REGISTRATION NO. /433 '/- T 7f� COUNTY
STATE MANHOLE REFERENCE ' d LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
I/ PUBLIC SEWER @ $3.00 .S LSD TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @'$2.00
HOUSE SEWER CONNECTING TOP.C,
N0. C
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.N0. JOB N0. x.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
_ •
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 51 p 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ez) REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTItNGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE.PUBLIC SEWER.
7.
SIGNED THIS DAY,OF 19_ NEW HOUSE SEWER
OWNER OR N Ji CONNECT ADDITIONAL
OWNERS AGENT Y 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
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
DESCRIBED RESIDENTIgggLLL��'PROPER BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTEE }� ���
®F /-VfkLIDATION ROBERT A. WOOD
Y.0. CASH SUPERVISING MECHANICAL, ENGINEER
.I rJ 7 u'7