HomeMy Public PortalAbout5334 GLICKMAN AVE_Sewer__ ESOB-D
CAPPLICATION FOR PERMIT
esos-s-ss COUNTY OF LOS ANGELES1,
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
CASSATT D. GRIFFIN,Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss sr.
LEGAL
DESCRIPTION LOT N0. )� OWNER ' �ti�� JLG�sL LiLLkQ
BLOCK TRACTMAIL
ADDRESS
NO,OF BL
SIZE OF LOT �' OT
NOW ON LOT CITY TEL.N0.
USE OF
BUILDINGS r" DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR y 47
ADDRESS _ CONNECTION DATA
cy�c _
CITY ,:TEL-.N0. 4-- STATION 6 `�DEPTH r
STATE MANHOLE REFERENCE � UPPER
REGISTRATION N0. COUNTY v
NO. DESCRIP ON'OFT-WORK IFEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 Od
TYPE OF CONNECTION "LENGTH FROM
ITS AND/OR @ $8.00 ✓�
SEPTIC TANK,SEEPAGE PIT OR CURB P.L. M.L.TO P.L. Imo+
P
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TOJ t fid• P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. '7 /, JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK-PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO. -
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT $ 2 00 CONNECTION,CHARGE FEE
AUTHORIZATION I TOTAL FEE C3� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, i
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL,
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[I DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS,REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS E]
OF PERMITTE
O - VALIDATION ROBERT A.WOOD
CK. Y.o, CASH SUPERVISING MECHANICAL,ENGINEER
IL"Lo 3 3 G B� OCT 1'3 1 0 A 5.0 0ri