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HomeMy Public PortalAbout5424 MCCULLOCH AVE_Sewer__ cE SO 8 4"`/7 2 76A64A2L APPLICATI�� FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS cXv LOCALITY I oz -A-/ NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL `elf- rk w GE SC RjpTIRNLOT NO. OWNER --t — k�__ 8 OCK TRACT MAIL s.- ADDRESS NO. OFBLDG S. SIZE OF LOT NOW ON LOT CITY TEL, NO. USE OF DISTRICT No'l Gpoup I MAP ;---P ITN E SS 0 8Y U I L 0 NGS_, P 8 K COPT RACTO—', e 107 CONNECTION DATA I CITYSTAT.-N� DEPTH TEL. N 0. 3 STATE LIC LICENSE 1,10. MANHOLE REFERENCE CLASS LOWER No.7 Dys-��RIP`TiON OF WORK FEE TYPE O-F CONNECTION­-— LENGTH FROM NOOSE SEWER CONNECTING TO CURB _M.L.TO P.L. SEWER- @ P.C.NO. PUBLIC_ Z=3��l 0 SEPTIC CO. IMP,NO. JOB NO.______F�7SAND/OR DRA;NFIELD_ HOUSE-SF WER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. E DISPOSAL SYSTEM FlRiVAT I_11.11 N_EET7A0Dl-F!ONAL5L6-G.OR F F WORK 70 HOUSE SEWER @ wA.VER EASEMEIm�INITR.W. ATE OVERFLOW SEEPAGE PIT.DRAIN FIELD ku EXTN- CESSPOOL.DRY WELL,MANHOLE HWY. OR ST.WIDENING ABANDON HOUSE - - SEWER 04;.D44i4�SYSTEM STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL -__.CHARGES 6' CONNECTION CHARGE FEE L) AUTHORIZATION TOTAL FEE , REIMBURSEMENT OWNER'S PERMIT I HAVE AT THIS DATE A CONTRACT WITH THE. HEREIN NAMED CON- FE�- TRA ­TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING RA�HE P I_ APPROVALS DATE INSPECTOR'S SIGNATURE TO UB tC SEWER. SIGNED TH;S —DAY Of:�­--19— 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 DRA;NFI El D HE F HER AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH REGULATING ALL COUNTY ORDINANCES AND STATE LAWS REI�� -.B,ALL D SE W E RE. PLUM"lNG AN CESSPOOL DRYWELL L 1,r I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR I E Li TE. CENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL YS J-F.A-Al- OWNER OF, AND INTEND TO --- I P AT DISCONNECT PLUG AND A�AFIIRNIA OR THAT I AM T ME IN _NT IAI;.�PER ABANDON HOUSE SEWER _S;or RE-`-r IN THE N T,'t 'SS;I LGN AT U FrL- BA-,KFtLL SEPTIC TANKS 4- 'F PER. 7n+. SEEP.PIT(5) r3 CESSPOOLS []I -VALIDATION (CK ,Ni.0, CASH 2 4 0 '6A 642D-CE808-10-71 APPLICATION FOR PERMIT u, COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST AI FOR APPLICANT TO FILL IN LEGAL DESCRIPTION LOT NO. OWNER - MAIL BLOCK TRACT J ADDRESS -...... NO. OF BLDGS. - SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF DISTRICT NO. GROUP MAP pR'OCE SSED ©Y BUILDINGS BK PS ,.: yp• .gyp ' - CONTRACTOR Y> 3 d ADDRESS ;. _ ,., "� - �=' CONNECTION DATA CITY Q'� TEL. NO. y�` s°'v .3 STATION p ...r DEPTH STAT �^�f LIC s ✓ UPPER- ` qy p/�e .yq MANHOLE REFERENCE �' LICENSE NO,. +�"' CLASS L. �,.✓ - �! _LAIMGR. NO. DESCRIPTION OF WORK PEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO �-�, Y. CURB ,P.L. M.L.TO P.L. PUBLIC SEWER @ $7.00 / 1. SEPTIC TANK.SEEPAGE PIT- OR P.C.NO PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 d CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIYEE EASEMENT RECORD.INSTR.NO. DATE O WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFI.ELD a- --[. EXTN..CESSPOOL,DRYWELL. @ $5.00 HWY. OR ST.WIDENING O ALTER.REPAIR OR ABANDON HOUSE �- SEWER OR DISPOSAL SYSTEM @ $3.0 0 _ STATE ENCROACHMENT MANHOLE@ $7.00 PERMIT NO. 4. INDUSTRIAL WASTE APPROVAL Z CHARGES OWNER'S PERMIT $ 3 00 / CONNECTION CHARGE FEE OT AUTHORIZATION TAL 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 OWNERS AG€NT - F CONNECT ADDITIONAL BUILDING.OR WORK ADDRESS_ SEPTIC TANK,SEEP,PITS) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRA.INFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑ PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFQ RNIA OR TH�THE LEGIS. OWF, ANO INTEND TO DISCONNECT PLUG AND RESIDE IN, THE A VE SCRIBED''R SIDEWTI PROPERTY. ABANDON HOUSE SEWER SIGNATURE '-1:1 f �.. BACKFILL SEPTIC TA SJI❑ OF PERMITTEE' "1+ ❑ -- SEEP.PIT(S) ❑ C SPOOLS VALIDATION CK. If CASH j 8 7 4 C- .its 4,-J. I