HomeMy Public PortalAbout5231 GLICKMAN AVE_Sewer__ CESOB3
-62
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FDR
JOHN A, LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building N.
Temple City
FOR APPLICANT TO FILL IN
LEGAL Weber Dev ..
DESCRIPTION LOT NO. OWNER
BLOCK TRACT 27309 ADDRESS MAIL !)WEB V• �� eCity V •
NO. OF SLDGS. iftty •
62 818
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS Residence DISTRICT NO. GROUP MAP PROCESSED BY
PG
CONTRACTO ! /�
J � '
ADDRESSCONNECTION DATA '
CITY nSan Gabriel II X477 STATION DEPTH
2 OIC 52 5 2� ❑ COUNTEl STATE Y MANHOLE REFERENCE �f
REGISTRATIO f �l
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO .,ir Y. CURB P.L. M.L.TO P.L. C
PUBLIC SEWER @ $5.00 p.
NC.N
SEPTIC TAK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $IO.00 CO. IMP.NO. JOB NO.O.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAW 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
L+ PERMIT $ 2 00 WASTE APPROVAL
OWNER'S CHARGES
AUTHORIZATION 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 OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS new BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULA INC
PLUMBINGAND S ER CESSPOOL [IDRYWELL ❑
I HEREBY CE I THAT 1 AM PROPERLY REGISTERED ND/OR ALTER.REPAIR,SEWER OR
LICENSED AS UIRED BY LOS ANGLES COUNTY NO ATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA THAT I A THE LEGAL OWN OF, NO END TO DISCONNECT PLUG AND
RESIDE IN T E ABOVE DESCRIBED RESIDE AL 0 ABANDON HOUSE SEWER
SIIFE
OF R
BECKFILL SEPTIC TANKS
OF PERMITTEE 5EEP.PIT(S) ❑ CESSP90LS ❑
VALIDATION ROBERT A. WOOD
CK, M.0
SUPERVISING MECHANICAL ENGINEER
. CASH
i�t110 0 2 9 1 J;lfd 2 8 1 D