HomeMy Public PortalAbout5221 GLICKMAN AVE_Sewer__ T3eLE CITY
6A642-62
7 D APPLICATION FOR PERMIT
6A642 '
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
ING 5221 N Gl1CkZI1AT1 AVe
JOHN A. LAMBIE, County Engineer ESS • .
WILLIAM A. JENSEN, Sup't of Building e1IIj �m l ty
ITY
e
FOR APPLICANT
i]TO FML INLEGAL
s 5T.
DESCRIPTION LOT NO. 26 OWNER Weber Dev.
MAIL
BLOCK TRACT 27309 ADDRESS 5926 N. Temple CLty Blvd•
NO. OF BLDGS. emp Oi y At . 62
SIZE OF Lkea NOW ON LOT CITY TEL. NO.
USE OF
iden Ce
BUILDINGS - DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOHenr B Vega 's- //{
ADDRESS �C3245 N. Iva.r Axe . .{. CONNECTION DATA
CITY So . San Gt ir.�el At . 0-477 STATION -4,. DEPTH
❑ STATE MANHOLE REFERENCE 1 UPPER
REGISTRATION . El COU
NTY !
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB .L. M.L.TO P.L. „
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. V
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I 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 HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N<MED 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 HOUSE SEWER
OWNERS AGENT_ now
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE SEPTIC TANK.SEEP,PIT(5)
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
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RE ED BY OS ANGLES COUNTY/AND TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT I A HE LEGAL OWNER O , AND NTEND TO DISCONNECT PLUG AND
RESIDE IN, T ABOVE SCRIBED RE TI PROP RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS E]OF PERM 7 SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH
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