HomeMy Public PortalAbout5215 GLICKMAN AVE_Sewer__ I
I
II TME'LE CI TY
76A642D
1 -62 APPLICATION FOR PERMIT
6A642
I COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS 5215 T O
WILLIAM A. JENSEN, Supt of Building
LOCALITY Tem 1 e Cit
FOR APPLICANT TO FILL IN
NEAREST
ROSS ST. Randwi ck Dr.
LEGAL
DESCRIPTION LOT NO. 27 OWNER
MAIWeber Dev.
L 5926
� 77 D a
BLOCK TRACT ADDRESS 2 6 1.I. e A Cit D1V(!_.
SIZE OF LOT NOW OON LOTS 1 CITY Temple Cijr�r.. NO. At . 62818
�]
BUILDINGS Residence DIST RICTNO. GROUP MAP PROCESSED BY
eery ega //,y BK PG
CONTRALTO
ADDRESS So . San Gabriel At . 0-4 CONNECTION DATA
CITY TEL. NO. STATION / DEPTH
IS
❑ STATE MANHOLE REFERENCE
REGISTRATIC�S' 02525 ❑ COUNTY t�
LOWE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.N0.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. .108 NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
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
EXTN.,C ESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OF 19_
OWNER
OWNERS AGENT_ new NEW HOUSE SEWER
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAT NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY TI$A M PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REDUIR BY L ANGLES COUNTY A ST#TE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH i AM T LEGAL OWNER OF, D 1 END TO DISCONNECT PLUG AND
RESIDE IN, THE OVE DES,-- IBED RES ID IAL OPE Y. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS '❑
SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATIOlY/"1 ROBERT A. WOOD
���// SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH