HomeMy Public PortalAbout5346 MCCULLOCH AVE_Sewer__ 76A642D ` APPLICATION FOR PERMIT
COUNTY OFLOS ANGELES SEWER-SEWAGE DISPIO
DEPARTMENT OFF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Hu1LDING
IOI'IN A. LAMBIE. County Engineer ADDRESS .ry
WILLIAM A. JENSEN, Sup'f of Building
LOCALITY �.-
NEAHEST
FOR APPLICIITT TO FILL IN
LEGAL
DESCRIPTION I,OT NOS �,. / f .y., L. �� OWNER
MAIL
BLOCK _. TRACT f' - ADDRES.� ,'y1r'J
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NO. OF SLOGS,
517E OF LOT NOW ON LOT yy CITY ✓� '""� 9--;y,�+Y' NQ 6 ,�r y
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ONT''RACTOR
ADDRhss i j CONNECTION DATA y
j STATION DEPTHCITY TFL
MO. _&
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NTMANHOLEREFERENCE
N
REGIS RATIONO
NO.. DESCRIPTION OF WORK FEE ..'i'YPE OF CONNECTION LON^TH FR3,4, .
�f
HOUSE SEWER CONNECTING TO _._-. .._.- .. _
_
_'F _.f* Y. CURB p L,. M.L.TOP'.L.
P PUBLICSEWER
. _ :a - , P c.NO
SEPTICTANC, EEFqGE PIT OR _ SOB NO
.-
ITS AND/OR DFAINE EL.D $t0.O4 CO.IMP. -
---
_
rtO WER CONN TEM TO
FRIVA TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE:SED SP05.4i SYSTEM � $3.00 '"/
-- - - -- ---- -- ---r. ..___ .---- --- ---- -- -
�'GNNEOT ADDI ZONA BLDG OH gFFiDRV1T rwA!v ER En�EMkHc I RECORD INS7R NO. �DATE
I
WORK'('O I-`OUSP:SEWER � 53:0![)
OVF_RFL-OW SEEPAGE ri,.DRA!NFIELD _
EX7 N..GES$PODL,ORYWFLL.MANHGLE 55.0('i
_.__. + HWY.OR T.WIDLf�!lNG +y
ALTER,RE PAIFtOR A6A NOON HOtJ5f_ -- aTm
SEWER OR DISPOSAL SYSTEM $3.40 T_--. .-_..-.__ STATE ENCROACHMENT
PERMIT NO.
--... --- -- --- -- -- — - INDUSTrIAL
WASTE APPROVAL
O lM S`l i-.sR+ A_... CHARGES
ERMIT5 2: 00
AUTHORIZATION OTAL FEE CONN-- -- --- -- --- - -------
FEE
- FEEN
CONNECTION....._. -- ECTION CHARGE FET ___- -- --------_-__---- _- --- -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FETE
'fRACTUR TO CON NEC .S-
'T' THE ABOVE DESCRIBED EX. TI:N< DWELLING
TO TfH_ PUBLIC SEWER. APPR®Y ALe3 OADATE (INSPECTR'.SIGNATURE
-
SIGNED THIS -.--_—.DAY ®F---- ------ -'—'19— -__. ---- -'--- }_- .�..L.- ---
OWNER 073 - � �j NEW HOUSE°iEWJ£R.
OWNERS AGFNT__ .__- ----_. -- CONNECT ADDITIONAL
6U I LDI NC-OR WORK
ADDRESS __- _..__ ._.__ _ .__.-.._
IL
SEPTIC TANK.SEEP,PLT(S)
f N .EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND,'OP_ DRAINF'IELD
AND C
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH A1_L 'COUNTY ORDINANCES AND S'iATE LAWS REGULATING �-
PLUMSING AND SEWERS. CESSPOOL [IDRYWE-L,[„ (� j
I HE.RCHY CERTIFY THAT I AM PROFERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
4..10E.N-1K A5 .REQtl{Rf_D BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA LIFSTRNfA OR THAT' 9 AM THE LEGAL OWNER OF, AND INTEND 70 6--C -"---T—I'------'
l$ ONN.ECT PLUG AND
RESIDE IN, 7'H F_ A - V �DE5CRIF{ED RESiCE?JT1AL PRO%=ERTY.
�. A45 ON HOUSE SEWER
SIGNATURE _ ,r'� y """" BACKFILL-SEPT[IIC TANKS IJ -'--------_-- -
OF PERM.FT'TEE '°.f + FEEP.PIT(S) ;� CESSROO S I
VALIDATION ROBERT A. WOOD
-SUPERVISING MECHANICAL ENGINEER
6 9 4