HomeMy Public PortalAbout5304 GLICKMAN AVE_Sewer__ D
S&E-6APPLICATION FOR PERMIT 1
g 68DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer _
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYNEAREST
FOR APPLICANT TO FILL IN CROSS ST.
DE CRIPTION LOT NO. a OWNER
BLOCK TRACT (�b MAIL
.� ADDRESS �
v
NO. OF BLDGS, CITY TEL. NO.
SIZE OF LOT Q 3X�(,t,NOW ON LOT �--
USEOF DISTRICT NO. GROUP MAP
BUILDINGS .r v- t� BK PG
CONTRACTOR ,
NECTION DATA
ADDRESS ��/G/f t'%J CON
i^
STATION DEPTH
CITY ryTEL.
j�NO. J17(� MANHOLE REFERENCE / PPE
REGISTRATION NO. /a / ❑ STATE
J9.�NTY
No. DESCRIPTION OF WORK FEE �p TYPE OF CON ECTIO LENGTH FROMHOUSE !"✓
PUBLIC SEWER EWERCONNECTING TO @ $3 SO �` P.
l M.L. TO P.L. J
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. I L� JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. _ I� NEW HOUSE SEWER
S
SIGNED THIS- OF C� 1�+ CONNECT ADDITIONAL
OWNER OR Vj _BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE HAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND TATE OF ABANDON HOUSE SEWER
CALIFORNI HAT 1 AM THE LEGAL 0 R OF ABOVE - DD
DESCRIB RESIDE TIA ROP RTY, h BACKFILL SEPTIC TANKS❑
SIGNAT RE SEEP. PIT(S) ❑ CESSPOOLS
OF PE ITTEE
JOHN A. L IE, COUNTY ENGINEER �,FjLIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. O. CASH
4.5 " 10
`
CEa63-E4 APPLICATION FOR PERMIT
�EAEdzD COUNTY OF LOS ANGELES
' DEPARTM$NT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISIONBUILDING S�0
JOHN A. LAMBIE, County Engineer ADO HE55
WILLIAM A. JENSEN. Supt of Building r
LOCALITY �
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL '
DESCRIPTION LOT NO. OWNER
�- MAIL
BLOCK TRACT ADDRESS
' NO. OF BLDGS. -13]
/ 2 L
SIZE OF LOT NOW ON LOT CITY C TEL. NO. GJ �J
USE OF 1
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
_ BK PG
CONTRACTOR ``�
ADDRESS , CO ECTIO DATA
CITY TEL. NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO, COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.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. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM $3.00
139
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT 1111 EASEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD (�
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 W
ALTER, HOUSE HWY,OR ST.WIDENING p_
SEWER QG�Rik SYSTEM Q $3.00 STATE ENCROACHMENT - N
PERMIT NO. (.. • .C�
INDUSTRIAL
WASTE APPROVAL
CHARG
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE /
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TOA THE
TRCTORPUBLIIC SEWER ONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL � L •�
BUILDING OR WORK v (/
ADDRESS
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 COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR [BACKFILL
ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFSEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWN R OF, AND INTEND TODISCONNECT PLUG AND
RESIDE IN, THE AB VE DESCRIBED RESIDE IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE SEPTIC TANKS ❑OF PERMITTEE' EEP.PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
l 5 0 1 61-0 JUA11 D 5.0 0
I
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