HomeMy Public PortalAbout5343 GLICKMAN AVE_Sewer__ ICE8o828.59 A LIGATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER y
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN,SAF
of Building 'LOCALITY
FOR APPLICdA�yNT TO FILL IN caoss sr/.LEAL
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DESCRIPTION LOT N0. 'JLt � OWNER
BLOCK TRACT MAIL
ADDRESS
/y N0.OF BLDGS.
SIZE OF LOT (J NOW ON LOT CITY TEL. NO.
USE OF
DI DISTRICT NO. GROUP MAP OCESSED BY
CONTRACT
—1 BK P
CONTR `(!
ADDRESS J .r�z� CONWECTIOR DAT
CITY 7 TEL.NO. STATION DEPTH
REGISTRATION NO. ��❑ COUNTY
n STATE MANHOLE REFERENCE ` � UPPER
NQ. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO --yy
PUBLIC SEWER @ $3.00 J ' TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. .CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 .
OVERFLOW SEEPAGE PIT,DRAINFIELD
_ EXTN.,CESSPOOL.DRYWELL @ $2.00
.HOUSE SEWER CONNECTING TO 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 +
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMEDNN-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING• DWELLI G APPROVALS DATE INSPECTSIGNATURE.
TO THE PUBLIC SEWE , !f'A
SIGNED THIS---L1—` DAY OF +/ p/ ///t/ 19_ NEW HOUSE SEWER
OWNERSAGENT- �'• +'' IM I \ �` 1�(':-?-/�� �' ;`.IiOWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS iS SEPTIC TANK,SEEP.PIT(S)
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 ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING gLTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF - ABANDON HOUSE SEWER /
CALIFORNIA OR THAT I AM THE LEGAL WNER OF THE ABOVE BACKFILL SEPTIC TANKS El
RESIDENTIAL PR ERTY
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE � "`�
OF VALY ROBERT WOOD
CK. a..0.o, CASH SUPERVISING MECHANICAL ENGINEER
LfP1749 J € 275.a0