HomeMy Public PortalAbout5210 GLICKMAN AVE_Sewer__ mM-13, LE CI
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76A642D APPLICATION FOR PERMIT
16A642
COUNTY OF LOS ANGELES SEWER—SEvVAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING s�
JOHN A. LAMBIE, County Engineer ADDRESS 52 p N. Glickman Ave
WILLIAM A. JENSEN, Sup't of Building LOCALITY Tomple City
NEAREST teen
FOR APPLICANT TO FILL IN CROs Sr.
LEGAL
DESCRIPTION LOT NO. 2 OWNER Wahtmr Day
BLOCK TRACT 27309 ADDRESSAIL5926 N. Temple Cit Blvd.
SIZE OF LOT NOWOON L TS CITY Temple Cjj. LyNoAt 62818
USE OF e$ en - e
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTORHenry B - Vega =
Z
ADDRESS 5245 N. Ivar Ave CONNECTION DATA
CITY So ♦ Sen Gabriel 0-477 STATION DEPTH
OWER
REGISTRATION
4P2525 ❑ STATE El COUNTY L7--�L MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM �.
1 HOUSE SEWER CONNECTING TO Y. CURB - M.L.TO P.L. (}
PUBLIC SEWER @ :5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT ORx10 00 CO.IMP.NO. JOB NO. J U
PITS ANDOR DRAINFIELD
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. n.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD I
EXTN.,C ESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ x3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER ORy� �AT NEW HOUSE SEWER �� ✓�j _�_. ,I' ,�
OWNERS AGENT_ iie it CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTYf ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND S CESSPOOL ❑ DRYWELL ❑
IHEREBY C Y T AT I AM PROPERLY REGISTE D AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS OU IRE BY LOS ANGL COUNI ASTATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA R THAT AM 7HE LEG NER D INTEND TO DISCONNECT PLUG AND
RESIDE IN HE AB E DESCRIBED IDENT P ERTY. ABANDON HOUSE SEWER
SIGNATU
OF PE M BACKFILL SEPTIC TANKS ElEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CASH SUPERVISING MECHANICAL ENGINEER