HomeMy Public PortalAbout5606 GLICKMAN AVE_Sewer__ )o-ea
7eAea8AB*3D APPLICATION FOR PERMIT
COUNTY OF-L09ANGM- SEWER-SEWAGE DISPOSAL
DIPA$'LME T OF COUNTY ENGUMM
BUUMING ANL} SAFETY DI{fIr9IQx ADDRESS O
OHN A. LAbCliF. CommttT Ea '4■f
A. LF3(BEN, SnP•6 93 Euu�uy
LOCALITY
NEAREST
FOR APPLICANT TO FILL CROSS c-r.
b KsCRII-7ION LOT NO, D OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF 5LDG0.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
Utl[ OF DISTRICT NO. GROUP MAF GCl/ ■Y
■UILDINO■
eK PG f
CONTRACTOR
ADORE"
O CTIOx DATA
CITY Tw NO. 7 < STATION11A L9
DEPTH /
R[G15T)IATIOM NO. COU NTy MANN OL[R[F[R[NC[ / LOWER
NO. DEBCRI-PYLON OF WORK FEE TYr[OF CONNECTION [MOTH FROM A
MOUS[■ [R CONN[CTINo TO �+ Y. CURE P.LL M.L.TO RL
FU■LIC S[YV[R O Se.00 d r.C.NO. /
• PTIG ,t S F o[F CO,IMF.NO. JO■N0. Q
FIVE AND/QI SRAIN FI[L.D SIO.00 V
HOUSE.."CONNECTING TO T7 UNK PER41T?CO. ROAD TERNIT H
FRIVATS DISPOSAL SYSTEM 59.00 9H
E
CONNECT ADDITIONAL■ G.OR AFFIDAVIT I 1AfTS5 I rAS[■[RT RECORD.INSTR.NOT DATE
WORK TO HAUS[SEW[R $3.00
OVERFLOW SEEPAGE PIT,DRAINFI[LQ
IXTN.,CKXSF00l,DKYWlLLL-MANHCLI[0 55.00
AL PA R ASA DOHOUSERWY.OR ST.WIDENING
■EWERR ODISPOSAL SYSTEM < $3.00 STAT[ENCROACHMENT Z
P[RMiT NO.
IND /TRIAL
W APPROVAL
CHAFW
OWNER'S FEaMT . 21 Oo t
AUTHORIZATION TOTAL, FIE Q CONNECTION CHARGE F �r
11 HAVE AT THIS DAT[ A CQNTRACT WITH THE HEREIN "MICD CON- REIMEORS[MENT FU
TRACTOR TO CONNECT TN[ ABOVE DESCRFO D LXISTING DWELLING
TO THE PUBLIC • AMOVAM DATE INSPECTOR'S SIGNATURE
81QNED THIS DAY OF 1y /
OWNER OR _J NEW HOU"S[W[R •TrZ'p
OWNERS AGENT CONNECT ADDITIONAL
_ ■WLDING OR WORK
ADDRESS ■EPTLC TALK.SEEP,PIT 4X
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIEL.D
AMD STAT[ THAT THE ABOVE IS CORRECT AND AGR[[ TO COMELY
WITH ALL COUNTY ORb INAN_ES AND STATE LAWS REGUL.ATINO
PLUMING AND S[W ERS. CESSPOOL ❑ DREW ELL El
ry[R[■Y CERTIFY THAT I AM FROFEhI,Y RIGIST;RED AND/OR ALTER,REPAIR,S[W[h OR
LICEN0FD AS REOLj1RED BY LOS ANGLES COUNTY AND STATE OF SWAG[DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM TH[ LEGAL OW N[R OF, AMC) INTEND TO OISCONN[CT PLUG AND -
RES IN, T-HE ',BO ESCRIS[D R I TIAL PROPERTY. ABANDON HOUSE SEWER
SIGMATU RK ■ACKFILL SKF TANKS ❑
OF P[1tM LTTE[ LJ CL/1 P OO 1.S
S[[P.FIT(S)
ALIDATIO EWOOD
BUPERV1OB RT A. FCAL ENGINEER
CK. M.O, CASH ROBERT A.
9 1 4 2 f,f 1 8 ? 0 18 0.0
`� 4 5,, i' '( 21 1 0 D 7.00