HomeMy Public PortalAbout5640 GLICKMAN AVE_Sewer__ CEAAPPLICATI FOR PE FIT u
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COUNTY OF LAS ANGEI. SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eu1LDING
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FOR APPLICW TO FILL INLKOAL
DESG RIPTI ON LOTN OWNER
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(LOCK TRACT ADDRESS
NO. OF BLDGB.
SIZE OF LOT NOW ON LOT CITY TEL NO.
US[ OF PROCESSED
DISTRICT NO. GROUP MAF CESD BY
■UILDINO■
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CONTRACTOR
ADDRESS CO N DATA
STATION DEFTH
CITY TEL NO.
R000NTYnA- YANHOL[REFERENCE
REOISTATIOIt NO. LOWER
NO. DESCRIPTION OF WORK I" TYPE OF CONNECTION LENGTH FROM
HOUSE■EWER CONNECTING TO Y. CURE F.L. M.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO. }.
IN O I OR CO.IMF.No. JOB NO. D.
FITS AND/OR DMINFIELD !110.00 O
OUSE■E1Y[R CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. L)
PRIVATE DISPOSAL SYSTEM SB.00
CONNECT ADDITIONAL aLbo.6h AFFIDAVIT RECORD.INSTR.NO. DATE OL
WORK TO HOUSE SEWER $2.00 O
O R OW SEEPAGE PIT,DRAINFIELD r
EXTN.,C[SSPOOL,DRYWELLMANHOL[0 Ee.00 LLVl
AL ARO A HWY. OR ST.WIDENING
[R OR DISPOSAL SYSTEM STAT[ENCROACHMENT N
r PERMIT NO. Z
INDUSTRIAL
WAST[APPROVAL
OWNEA'S PERMIT s zoo CHA,
CONNECTION CHARD[FEE
AUTHORTLATION TOTAL. FEE
•1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAmt CON- REIMBURSEMENT FEE I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXILTIHO dWELLINO
TO THE PUBLIC SEWER. APPROVAL,$ DAT[ INSP ECTb R'S SIO NATU RE
SIGNED THIS--- DAY OF lO_
OWNER OR NEW HOUSE SEWER
�r OWNERS AG[NT CONNECT ADDITIQNAL
■U ILDI NO OR WORK
ADDRESSE[PTIC RTANK,SEI".PIT(S)
1 HERBY ACKP40WLKDGH
E THAT I AVE REAP THIS APPLICATION AND OR DAINFIELD
AND STATE THAT THE ABOVE If CORRECT AND AGR[[ TO COMPLY
WITHALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUM SING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 ED ER
AM PROPERLY REGISTREAND�OR ALTER,REPAIR,SEWER O
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL 9.WNKR OF, AND INTEND TO DISCONNECT PLUM AND
RESIDE IN, TH[ ABOVE RI■ R ENTIAL PROPERTY. ABANDON HOUSE S[W[R
Lo,
ATUR[ BACKFILL S[P•�ICTAHkI PER YiTT tl QEF, 'IS
T(S) LJ ANKSOOLJ
YAIMATION ROBERT A. WOOD
!.&-.K.V M.0. CASH SUPERVISING MECHANICAL ENGINEER
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TeA642D ' APPLICATI FOR PE MIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMaTT OF COUNTY ENGn=
BUZI)ING AND SAFETY DIVISION euC H
OEN JL LAY M A.=
A. TEMON, &,p'f of&alldbiq
LOCALITY F
NEAREST
FOR APPLICANT TO FILL. IN C"Df■ ST' � f r7 k7
D[SCRIPTION LOT N OWNER
MAIL n`
■LOQK TRACT ADQRES■ ✓ a L{I
SIZE OF LOT NOW OON LOTS L/I' CITY S Q� TIL NO.
St Of DI/TRILT NO. GROUP MAP PROCEJ/ID BY
■(JILDINGf
■K PP
CONTRACTOR V c `
ADDRX" 7 z2- re H o v ,�f CONNECTION PATA
CITY IQ +r T'[L HO. 8 ID 7
fTASI OIf' DEPTH .
REGISTRATION NO.
G O COUNTY MAnHOJ..[R[F[R[NC[ [R
No. DESCRIPTION OF WORK FEE TYPE of coNNtcrlon L[Nd•YH FROM
HOUS[S[W[R CONNECTING TO CURE P,L M.L.TO P.L
rub IC SEWER SE.DO O
B DTIC ANK,f[ [P OR P.4 NO.
PITS AND/OR DRAINFI ELD 810.00 CO.IMP.NO. JOr NO. O
NOUS[/EWER CONNECTING TO TRUNK PERMIT NR
O_ ROAD PERMIT NO. / U
PRIVATE DISPOSAL fYSTEM 89.00 v
CONNECT ADDITIONAL BLDG. AFFIDAVIT •Alyn —101"T RECORD.INS".NQ. DA7[
WORK TO HOUSE SEWER 8 .00
OVERFLOW SEEPAGE PIT,DRAINFIELI
E TN.,CESSPOOL,DRYWEI-LMANHOL[0 819.00
ALT".REPAIR OR ABANDON O HWY.OR ST.WIDENING
SEWER OR DI/PO/AL fYSTIM 4p 89.60STATE ENCROACH
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHAYId t1
WNM"S PERMIT s z 00
AUTHOFMTION TOTAL FEE7100Cb NN[CTION CHARaE FI[
'1 HAVE AT THISDATE A CONTRAC
RT WITH THE
I HEREIN NAMED CON- 1([IM■URS[MtNf FEE
TACTOR TO CONNECT THE ABOVE DESCRIBED p
TO TH[ 1,U LIC f [ Q / APPROVALS DATE INSPECTOR'S SIGNATURE
81(3NED T}il1�DAY /Tppf / IG
OWNER OR �� NEW HOUSE SEWER
OW N9RS AO �, y4 Srr�'
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,S[Er,PIT(S)
1 HERESY ACKNOWLKDa[ THAT 1 HAVE READ THIS APPLICATION AND/OR DIA 111 FI ELD
AND STAT[ THAT THEAtOVE 18 CQRRICT AND AGREE TO COMPLY
Y
WITH ALL COUNTORDINANCES AI(D STATE LAWS REGULATING
PLUM■ING AND BEWERS. CESSPOOL El DRYW[LL ❑
1 H[RSSY C[)ITIFY THAT I AFI PROMRLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LIC[NBED AS REQUIRED SY LOS 1NGLIS COUNTY AND STATE OP SEWAGE DISPO*ALQYS3-EM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DI/CONN[CT PLUG AND
RESIDE IN, TH8�A*OVKLSCRIB RESIDENTIAL rRO"RTY. ABANDON HOUSE SEWE)I
SIGNATURE S.ACKFILL B[P'�IC TAMKS Q
QF P[RMITT SEEr,PITS) LJ CXAS O L/
VALIDATO ROBERT A. WOAD
6UPERVIEIN6 MECHANICAL ENGINEER
CK. M.D. CASH
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