HomeMy Public PortalAbout5216 GLICKMAN AVE_Sewer__ TMIPLE CITY
l 76A642-62D APPLICATION FOR PERMIT
! 76A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS (�
WILLIAM A. JENSEN, Sup't of Building LOCALITY yeTZ 1 C� •
NEAREST Green St
FOR APPLICANT TO FILL IN CRo55 ST. •
LEGAL
DESCRIPTION LOT NO. �J 1� OWNER
Weber j7J*1ev
BLOCK TRACT -�(tJ09 MAIL •
ADDRESS 59P,8 NA "PeMple - d •
O
SIZE OF LOT NOW ON L TS CITY T. CVL. No,- At .
]„ 6 8
USE OF a encs
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOVmmq
ADDRESS 3245 N Iv AveV CONNECTION DATA Cy
CITY So . San Gebmiel At . O-47172 STATION DEPTH
REGISTRATION 0:525 ❑ STATE MANHOLE REFERENCE
❑ COUNTY OWER
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION -1 LENGTH FROM
1 HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. P.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. .'
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. l/.tom/ S�J�>' ,, V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEN EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL 'FEE CONNECTION CHARGE FEE
1 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. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR new NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL `
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(5)
AND STATE THAT T E A I` IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNT O INA CES AND STATE LAWS REGU ATING
PLUMBING AND/g W S. CESSPOOL ❑ DRYWELL ❑
I HEREBY C RT Y THAT I AM PROPERLY REGISTERE AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS R UIRED BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O THAT THE LEGAL O ER OF A INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH AB E ESCRIBED RE NTIA P •P TY. ABANDON HOUSE SEWER
S IGNATUR BACKFILL SEPTIC TANKS ❑
OF PER TEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH