HomeMy Public PortalAbout5422 MCCULLOCH AVE_Sewer__ '6A 6420-CE808-10-71 APPLICATION FOR PERMIT �� �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING f
ADDRESS m JTr' e
LOCALITY 7
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. ✓ -
LEGAL
DSCRIPTION LOT NO.
EOWNER ,. L{. � � '�j P•t` �`
MAIL
BLOCK TRACT - ADDRESS
NO- OF BLDGS. "J'�-tel
SIZE OF LOT NOW ON LOT CITY TEL. NO. ! /
USE OF
BUILDINGS DISTRICT NO. GROUP "AAP PRQCESSED BY
BK P5 \,
EONTRACTOR ' !l -� rx. :•J 1 ti. - r1, f"i t
ADOREsss 4.-1l� lL- ; G;. /+(y r CONNECTION DATA _ _ !•
CITY yy,�TEL. No.
,s s{6J STATION L#- DEPTH
STATE r"' ��* /y LIC - !! ! UPPER
LICENSE NO. °�'- f D / CLASS �'"� % MANHOLE REFERENCE LBWS
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $7.00 —
SEPTIC TANK.SEEPAGE PIT OR P.C.NO, r
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Q
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE (�
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. 0 $3.00 O
. .
ALTER,REPAIR OR ABANDON HOUSE HWYOR STWIDENING
SEWER OR DISPOSAL SYSTEM $3_00 _ STATE ENCROACHMENT W
MANHOLE @ $7.00 PERMIT NO.
--- -- INDUSTRIAL h
WASTE APPROVAL z
OWNER'S PERMIT $ 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION 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 1Q_
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT -
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS__
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS- CESSPOOL ❑ DRYWELL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRE BY LOS ANGLES UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH - i A THE LEG,,��� NE OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A O E SCRIBED`RFf$ID IAL PROPERTY. ABANDON HOUSE SEWER _
1 r
SIGNATUREl
4' �„ BACKFILL PTI TANKS
OF PER MTTTEE_ `� *y / ---- SEEP.PIT( ) [ CESSPOOLS ❑
VALIDATION CK. M.O. casH
6 7 ti r"-ir01 L1 1 u 0 � v.� � ♦�.;