HomeMy Public PortalAbout5340 GLICKMAN AVE_Sewer__ CESOO-D
EBD9.8•H9 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONZADCDRESS
LDING ,
JOHN A. LAMBIE, County Engineer �J ✓
CASSATT D. GRIFFIN, Sup't of BuildingALITYN.��C
FOR APPLICANT TO FILL IN ceoss ST
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS. /
SIZE OF LOT (� NOW ON LOT I CITY TEL.NO.
USE OF J
BUILDINGS DISTRICT NO.1 GROUP MAP PROCESSED BY
(: _, -- B
CONTRACTOR iv
j
ADDRESS - CONNECTION DATA
CITY TEL.N0. -rte!❑❑/(/{ STATION �' DEPTH
REGISTRATION NO. �� �- � H COUNTY VATE MANHOLE REFERENCE UPPE
NO. DESCRIPTION OF WORK FEE ` R
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD @ $3.00 CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EX TN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO C P.C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 5 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 6- ad 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. / _` r. r�.-
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❑ DRYWELL❑
LDESCRIBED
COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
RESID TIAL PROPERTY. BACKFILL SEPTIC TANKS❑E �, SEEP. PIT(S) ❑ CESSPOOLS❑ITTE
®P VALIDATION ROBERT A.WOOD
OK, M.D, CASH SUPERVISING MECHANICAL ENGINEER
1 03a66a; OCT 31 0A 5.00