HomeMy Public PortalAbout5420 MCCULLOCH AVE_Sewer__ 6A 642D-CE608 - 10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / yoc
ADDRESS - � � o^� /`�4' e o
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN =ROSS ST. - "-Cl'�E/-�/p•
LEGAL
DE_SCRIPTfON LOT NO.
OWNER $.MAIL
BLOCK TRACT - ,{.a ADDRESSNO. OF BLOGS.SIZE OF LOT NOW ON LOT CITY TEL, NO.
USELD NGS OF t--A
NO. GROUP MAP '�R6`C�S 5.E.D BY
BK P^a
CONTRACTOR r :� ., a 1 %. ! �• ,
ADDRESS " , " _ C NNECTION'DATA
_ DEPTH
CITY TEL. NO. -
STATE LIC y+ Iwo
LICENSE NO., e -. CLASS E REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE E OF CONNECTION _ LENGTH FROM
HOUSE SEWER CONNECTING TO CURB :,p_,S,_�-- M.L.TO P.L.
PUBLIC SEWER $7.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
NO. JOB NO. -
P175 AND/OR GRAINFIELD @ Sf0.00 -
HOUSE SEWER CONNECTING TO ERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 83.00 O
CONNECT ADDITIONAL BLDG.OR IT WAIVER EASEMENT RECORD.INSTR.NO. DATE u
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD I=
EXTN..CESSPOOL,DRY WELL. $5.00 HWY.OR ST.WIDENING O
.
ALTER,REPAIR OR ABANDON HOUSE ¢-
SEWER OR DISPOSAL SYSTEM _� 83.00 STATE ENCROACHMENT W
MANHOLE $7.00 PERMIT NO.
INDUSTRIAL In
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT $ 3 00
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
f l �♦ �'
OWNERS AGENT --
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH I A THE LEGAL N F. A D INTEND TO
Ah f DISCONNECT PLUG AND
RESIDE IN, THE ABO V. DE RIBED RES NT1A P PE RTJ'.
B '`� ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS F-1
OF PERMrTTEE .+4/y `'�_ L -r'" _ ❑ a''+ '•
SEEP.PIT(S) ❑ CESSPOOLS
ALIDATION CK. M.O. i CAS
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