HomeMy Public PortalAbout5612 GLICKMAN AVE_Sewer__ """"°
K. APPLICATION, FOR PERMIT 1
DIVISION OF BUILDING AND SAFETYS M E R-SEWAGE D 1 S POSA L
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Colmt7 of Los AnQ.las FADD�RUINS��
u WM.J. FOX, COUNTY HNGINCLt CAl1ATT D.GRIFFIN, Sur'T OF■UIL°IMa OCALI
FOE APPLICANT TO FILLIIII EAREST
SOSE
IT.
LEGAL / l
DESCRIPTION LOT NO. OWNER
DLO CE TRACT, MAIL
DRESS
NO, OF BLDG$.
SIZE OF LOT NOW ON LOT CITY - TEL NO.
USE OF
BUILDINGS DISTRICT N0. GROUP 12-7 I ■AP
GK PG
coNT>:ActoR
ADDRESS CONNECTION DAT1t
�' 0
CITY EL NO. �� STATION �� DEPTH
STATE O MANHOLE REFERENCE
REGISTRATION N0. 17
��D ❑ COUNTY PSR LOWER
TYPE OF CONNECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y vr1r, Y.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM T.00
CONNECT ADDITIONAL BLDG. OR CO. IMP,N0. JOB. NO. / ,7Z V
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCNNECT AND ASANIION SkVER STATE ENCROACHMENT
ANDPDR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAIHFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
6PECIAL CONDITIONS ONLY 2.00 CHARGES
i
K CONNECTION CHARGE FSE 61r �•
OWNEWS PEBMT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED E(ITSTIN❑ DW91,LINQ APPEOYALS DATE IHDPECTOR'S SIGNATURE
TO THE PUBLIC SEWS NEW HOUSE SEWER
SIGNED THI A 19
n L CONNECT ADDITIONAL'
OWNERS AGENOWNER OR i y BUILDING OR WORK
ADDR SEPTIC TANK,SEEP,PIT(C
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONrALTER,
OL❑ DRYWEII ❑
` AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGREPAIR,SEWER OR
PLUMBING AND SVWERS. DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/QRNECT PLUG AXD
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND GTATE OFCALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVEN HOUSEGEWER
DESCRIBED RESIDENTIAL PROPI'iRTY. LL t C TANKS
R t CF3 .
SIGNATURE
OF PKRMITTEE
WILLIAM J.FQX,COUNTY 13NGINKKi VALIDATION
ST _&5.04219 ,1024 3s ' 50.25th043x J024 4 4.50
By
DrPUTY DE-PUTT
BY r ST 1
(v ���Y DEPUTY t DEPOTY