HomeMy Public PortalAbout5305 GLICKMAN AVE_Sewer__ DEPAItrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
,�PUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
1� FOR APPLICANT TO FILL IN LOCALITY ,
BUILDING NEAREST
ADDRESS - _.- '1LZ- CROSS ST.
LOCALITY �� ' DISTRICT NO. SERIAL NO. PERMIT NO. c
NEAREST A S
CR05S SL
1,1 RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL -
ADDRESS �_ •`'; �' -N USE ZONE OCCUPANCY MAP
' I BK PG
F �
CITY TEL.NO.
CONTRACTOR CA3.ffornja SeVrer! gone*
CO.IMP.N0.
ADDRESS 1317 Cnl ?aY'QV@ AVS JOB N0.
CITY Wonteben o TEL.No11AT; } A TRUNK PERMIT NO.
REGISTRATION NO. OUNTY ROAD PERMIT NO.
LEGAL - �. STATE ENCROACHMENT
DESCRIPTION LOT NO. U` f PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.OF BL
NOW ON LOT
� _ CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE-
H-0—USES-EWER CONNECTING TO
PUBLIC SEWER a $ 3.50 RECEIPT N0. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO' I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00 i
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION /
CESSPOOL—DRYWELL DEPTH
SPECIAL CONDITIONS ONLY 2.00MANHOLE REFERENCE
— �Lx� LOWER
TYPE OF CONNECTION LENGTH FROM
PERMIT $ I 00 COBE P.L; M.L.TO P.L.
OWNERS -
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DES RIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THHE PU LIC SEWER
SIGNED THI1! DAY OF.. _._..._..._1 NEW HOUSE SEWER Y 1
OWNER OR /(�� CONNECT ADDITIONAL
OWNERS �AT �e�._/rx--- -.• - � l�C...�....._ BUILDING OR WORK
/1.�J
ADDRESS._.-....._.._.-._-._. SEPTIC TANK,SEEP.PIT(S)
................- ..... --------............--j AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL O
CA
TIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
I SEEP.PIT(S)❑ CESSPOOLS
SIGNATURE
OF PERM ITTEE-.-._--...--.:,...........................= -'= ---- -•---------•-----
76A642D 663 1/53 O/ y�