HomeMy Public PortalAbout5632 GLICKMAN AVE_Sewer__ 7BA842D �C, I T RAFL saf CU ■ V
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O':OUNTY OF LS AN ELECATI O N FOR R WER—SEPRMAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING l`
JOHN A. LAMBIE, County Engineer ADDRESS
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLI T TO CROSS ST. c'
LEGAL 944
DESCRIP 0 s OWNER
LO ° MAIL
ADDRESS
�. 0.OF BLDGS. or If
SIZE OF LOT OW ON LOT CITY TEL. NO.
USE OF
BUILDINGS < DISTRICT NO. GROUPI
ADDRESS � < MAP I PROCE ED BY
CONTRACTOR5;7 / j.� L"'��� BK PG f 1
,/ ) CO NECTION DATA
CITY L.NO. 7 STATION C.� DEPTH /
STATE MANHOLE REFERENCE PPER
REGISTRATION NO COUNTY G
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO s -
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION 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 TOP.C.NO. /„h
PRIVATE DISPOSAL SYSTEM @ $1.00 fR?r mvl.190. JOB N0.
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 DISPOS L SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I REIMBURSEMENT FEE
I HAVE AT DATE ATRACTOR TO CIONNECT THE ABO ET DESCRIBED EXISTINGWITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
THE PUBLIC SEW
, +
SIGNED DAY O �` / NEW HOUSE SEWER
OWNER0 CONNECT ADDITIONAL %f
OWNERS AGENTT BUILDING OR WORK
ADDRESS rSEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
LPERMWITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
I1111
BING AND SEWERS. SEWAGE DISPOSAL SYSTEM
EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
NSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
FORNIA OR THAT I AM THE LEG L OWNER OF T E ABOVE BACKFILL SEPTIC TANKS ❑
RIBED PROPERTY SEEP.PIT(S) ❑ CESSPOOLS ❑
ATURE
TTE
OF
- v LI.0. ROBERT A.A WOOD
_ n � SUPERVISING MECHANICAL ENGINEER
(oG'� CL Y.O. CASH
fAr" 3 5 Sci' 12 8 D 1 6 5.0 0 •�