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HomeMy Public PortalAbout5130 GLICKMAN AVE_Sewer__ 78A842D CE809 x•59 APPLICATION FOR PERMIT 7 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1 DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDIN77<p y ADDRESS CJOHN A. LAMBIE, County Encineer CASSATT D. GRIFFIN, Supt of Building LOCALITNEAREST FOR APPLICANT TO FILL INCROSS ST.' G`"' LEGAL / _ OWNER -cx / DESCRIPTION LOT NO. &wa BLOCK TRACT MAIL J ADDRESS aexsNO.OF BL15G � L „I., 'l� SIZE OF LOT NOW ON LOTS CITY /X TEL. NO. USE OF DISTRICT NO. GR OU MAP PRO ESSE Y BUILDINGS LCL"CC/N� BK PG CONTRACTOR Q ADDRESS ,�Sr `IS L ` ` CONNECTION DATA CITY �j TELL..NOO.",,f--, STATION © a o DEPTH STATE-� 7 0 MANHOLE REFERENCE 'i LOWER REGISTRATION N0. COUNTY �../ NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM SEPTIC TANK, PITS AND/OR DRAINFGELDT OR @ $3.00 Y. CURB P.L. M.L.TO P.L. 40 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL. DRYWELL @ $2.00 HOUSE SEWER CONNECTING TOP.C.NO. r � PRIVATE DISPOSAL SYSTEM @ $1.00 f0. ao9 . l WORK CONNEC H ADDITIONALUSE BLDG.OR @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO. SEWER OR DIISPOSAL SYSTEM R ABANDON HOUSE @ $1 00 STATE ENCROACHMENT PERMIT N0. INDUSTRIAL WASTE APPROVAL CHARGES OWNER'S PERMIT E 21 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE .S LS`G' REIMBURSEMENT FEE t CON- TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ NEW HOUSE SEWER OWNER ORCONNECT ADDITIONAL A OWNERS AGENT k 4' BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT HOUSE D CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PRQPERT BACKFILL SEPTIC TANKS ❑ SIGNATURE sJ r- �. SEEP. PIT(S) ❑ CESSPOOLS ❑ OF PERMITTEE - CCC -d�--• ®r VALIDATION ROBERT A. WOOD c�K.J Y.e. CASH SUPERVISING MECHANICAL ENGINEER