HomeMy Public PortalAbout5319 GLICKMAN AVE_Sewer__ J-
7 5-65
76A645-65
APPLICATION FOR PERMIT
6A 64
COUNTY OF LOS ANGELES SEWER—SEWAGI� DI POSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 'A� /,
JOHN A.LAMBIE, County Engineer ADDRESS Yom► y e
COLEMAN W. JENKINS,Sup't. of Building
LOCALITY r �
NEAREST �a O Jf V Q
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL / � y�
DESCRIPTION LOT NO. OWNER g< e?//'iA!�'i �V
MAIL ry
BLOCK TRACT 8 ADDRESS 5 vy
NO. OF SLOGS. Q
SIZE OF LOT (Z NOW ON LOT CITY G TEL. NO.
USE OF DISTRICT NO. GROUP
BUILDINGS BK PG MAP PROCESSED BY
c
CONTRACTOR
ADDRESSaf/f �(J CONNECTION DATA
STATION DEPTH
CITY LI D TEL. NO. � V
LICENSE LICENSE
NO. CLASS MANHOLE REFERENCJ -�L O , / Sv t R
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 S pQ �.
P.C.NO. a
SEPTIC TANK, SEEPAGE PIT OR CO.IMP. NO. JOB NO.
PITS AND/OR GRAINFIELD C $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM C $ 3.00 ix
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO. DATE O
WORK TO HOUSE SEWER C' $ 3.00 00
'ALTER' RE A OR ABANDON HOUSE `J
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
HWY. OR ST.WIDENINGUW 5ELVA�h 0.
DRAINFILLD
EXTN.,CESSPOOL, MANHOLE ? $ 5.00
STATE ENCROACHMENT Z i
PERCOLATION TEST C $ 5.00110
PERMIT NO. r
INDUSTRIAL
WASTE APPROVAL '
CHARGES
OWNER'S PERMIT �
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 HOUSE SEWER
OWNERS AGENT sa Z,� t CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I 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 ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED SIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL6GPoFFC-TAr+*� '
OF PERMITTEE
CESSPOOLSp
VALIDATION��,
CK. M.O.
8,.o JIUI.1 ED, 1 0 D