HomeMy Public PortalAbout5430 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 FNEAREST
ry
' 3 ✓ L/' fL IL.�
"y y
FOR APPLICANT TO FILL IN
LEAL
DESCRIPTION LOT NO. — - OWNER 1Go'Io;7` 1(/c
__--- MAIL '�. p ✓. �. � '
BLOCK _ TRACT ; / :_ ADDRESS ��";;yyN
SIZE OF LOT NOW OF LOTS CITY , "�.f /-'i"EL. NO. F>
USE OF
BUILDINGS DISTRICT ND. GROUP MAP PS PROCESSED BY
CONTRACTOR ✓.. �' ..� "" , `..
ADDRESS Y; -� _.�l,r / G.. CONNECTION DATA
CITY TEL. NO.
ry_ry �„ / STATION + DEPTH
- - a:�iTf f 4,-
STATELIC _ MANHOLE REFERENCE - UPPER
r.
LICENSE NO. qry CLASS
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB <, M.L.TO P.L.
PUBLIC SEWER Q $7.00 ,/ _
SEPTIC"LANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ,
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR A.FFIDAYIT waIYEE=CORD- INSTR,NO, DATE V
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD (k
EXTN..CESSPOOL.DRYWELL, $5.00 HWY.OR ST.WIDENING O
.
ALTER,REPAIR OR ABANDON HOUSE p.-
SEWER OR DISPOSAL SYSTEM $3.00 _ STATE ENCROACHMENT uj
MANHOLE
$7.00 PERMIT NO. d
INDUSTRIAL th
WASTE APPROVAL - z
CHARGES s
OWNERS PERMITs s 00
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 W6PEGTOR'S SIGNATURE
SIGNED THIS 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 TH15 APPLICATION AND/OR DRAINFIELD
ANDSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING 1�
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL 4
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
CE
LINSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALiFORN1A. OR THA �Q THE LEGAL OW�i'E F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB�? DCRIBED IDE.TIAL PROPRTY.
ABANDON HOUSE SEWER
SIGNATU RE
OF PERMffTEE _J/ �!' BACKFILL SEPTIC C1 SEEP,PIT(S) ❑ CEOPOOLS ❑
VALIDATION t' K, ,a1.D. ASH
b 1 16t"wv 11:I i. IJ D