HomeMy Public PortalAbout5405 MCCULLOCH AVE_Sewer__ 24690 INSERTS
78:4676661428 6-60 APPLICATION FOR � PERMIT, 1,�
4 �
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ✓� P.��
ADGRES5. ,.
JOHN A. LAYdfBfE, Countp En ineer
VVfLffAfM A. JENSEN, Sup't of Building LOCALITY
NEAREST '�•FOR APPLICANT TO FILL IN cROss sI I'' ,
LEGAL OWNER
DESCRIPTION LOT NO,
MAIL ..
BLOCK TRACT � �'. --� ADDRESS-
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO,
USF.OF DISTRICT NO MAP PROCESSED BY
BUILDINGS_ I BK PG
CONTACTOR `
ADDRESS fir'y ._` . ; '^ t ..., CONNECTION DATA
CITYTEL.NO. ,� 'sr _ �e STATION DEPTH
x b STATE MANHOLE REFERENCE UPPER
REGISTRATION N0, r `,T'l COUNTY LOWER
NO DESCRIPTION OF WO'KK FEE
HOUSE S_WER CONNECTING TO
PUBLIC SEWER___,__ Ca $3..00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P,L.
PITS AND/OR DRAIN FIELD @ $3,00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.. CESSPOOL,DRYWELL C $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE D!SPOSAL SYSTEM $1.00 CO.IMP, NO. JOB NO, a
Jar ORKTOHUEISEEBLDG.OR
WHOUSE @. $7.00 —11':
* TRUNK PERMIT NO. ROADPERMITNO, 0
ALTER,REPAIR OR All DON HOUSE STATE ENCROACHMENT
SEWER OR DlSPOSAI.SYSTEM @ $1.00 PERMIT NO. O
INDUSTRIAL - .
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEEt "w REIMBURSEMENT FEE
EIN NMECON.
T ACTOR TO CONNECT THE ABOVE DESCRIBED EI HAVE AT TS DATE A CON-TRACT WITH THE XISTINGADWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL I
OWNERS AGENT BUILDING OR WORK 1
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAiNFIELD
I HEREBY ACKNOWLEDGE 'THAT I HAVE READ THIS APPLICATION
AND STATE T14AT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL L DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE_DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGJSTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE LEGAL OWNER OF THE ABOVE
DE5CRiBED RESIDENTIAL PROPERTY.,.. BACKFILL SEPTIC TANKS ❑
SIGNATURE ..,. - SEEP.PIT(S). ❑ CESSPOOLS [.1
OF PERMITTE
EoVAIeIDATIO,N' ROBERT A. WOOD
CK. U.0. j CASH SUPERVISING (MECHANICAL ENGINEER
s
E
r
Y