HomeMy Public PortalAbout5356 MCCULLOCH AVE_Sewer__ `7 tiAEd2B •�-.. .�_s E-0153 Il.ss
APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
ADDRESS
JOHt'�I A. (._AMBLE, COUNTY ENGINEER - � -�-
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY "T' .
NEAR ST -'-----
-- - ----- FORAPPLICANT TO FILL IN CROSS Sr.
LEGAL --- OWNER
—DESCRIPTION LOT LOT N0. -_
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. v'
_SIZE OF LOT - NOW ON LOT CITY �;
USE OF A— —.-.__-- —
UILDINGS
-., ~'� DISTRICT N0. , GROUP ! MAP
B
BK PG
CONTRACTOR
_. , �
DATA
CO
ADDRESS CONNECTIONCONNECTION — --.-- -
?7 - 1� STATION 7 { DEPTH
TEL NO.. 9t _ ..---
3IANHOLE REFERENCE ✓ r _- PPER\'
REGISTRATION N0. " COUNTY _._.
NO. j DESCRIPTION OF WORK FEE y TYPE OF� #:CTIgN LENGTH FROM I HOUSE SEWER CONNECTING TO { T ;pe" 7
", ;. ' 3 ,
PUBLIC SEWER _ _ @ $3.50 ....� �,_ ,= URB F.L. M.L. TO P.L.
---�—�. .— - '---__
SEPTIC TANK SEEPAGE PIT OR
D/ . -
PITS ANOR DRAINFIELD �
_ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDpO
_ EXTN ,CESSPOOL,DRYWELL,MANHOL,E 6a7 $.2.00 --CO, IMP.N0, >,I- "3 _08 N
-1 HOUSE SEWER CONNECTING TO -----
PRIVATE DISPOSAL SYSTEM (C[ $1.00 TRUNK PERMIT NO ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER C S 1.00 I - PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE ---- _--- --..-- _ _---
INDUSTRIAL
_ SEWER OR DISPOSAL SYSTEM - a $f,DO WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 11 00 —�`— --- ---- -----
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HAPPROVALS DATE INSPECTOR SSIGNAT REEREIN AMED CON- _..__.—
iRACTCR TO CONNECT E ABOVE DESCRIBED EXISTING DWELLING �
TO.THE PUBLIC SE NEW NEW HOUSE SEWER
SIGNED THIS - DAY OF Aq --_ —_ _-- —. -- ---
CONNECT ADDITIONAL I
OWNER OR �° -' BUILDING OR WORK
OWNERS AGENT ` -�• y ., ,: ----. -
EPTIC TANK,SEEP,PIT($)
ADDRESS - AND/OR DRAINF3ELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION '
ANSTATE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY .—CESSPOOL[- D.RYWELL0_
WITH ALL COUNTY ORD-INANCES .AND STATE LAWS REGULATING ALTER REPAIR SEWER OR —
PLUMBING AND SEWERS. _SE1kAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A.ND;'OR SEW G EDISPOSAL-SY D
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
N OUSE SEWER _
CALIFORNIA OR THAT I AM THE LEGAL OWtTiER OF_THE ABOVE, --- -- -- — — —_-- .—_
LP6'S�R,1�91) RES ENTI� - PROPER '�. "�,'' � ; BACKFILL SEP'T'IC TANQ49❑� SEEP.Pi7(S? i1 CE5�P09LS r1 T PERMITTEE
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IOI-I'N A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD,CHIEF PLBG, INSPECTOR
CK. N.Q. CASH
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