HomeMy Public PortalAbout5432 MCCULLOCH AVE_Sewer__ APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION %HLOING
A DRESS
—o-..'4-: ,_&—
jj
LOCALITY
FOR,APPLICANT TO FILL IN NEAREST
DESCRIPTION LOT NO. OWNER
LEGAL
MAIL
BLOCK TRACT —.EBB
NO. OF BLDGS.
S.IZE-OPLOT NOW ON LOT CITY TEL. NO.
DISTPICTNO.1 GRDUP 'AAP 4.1�.SSED BY
'j � F
USE OF
BUILDINGS
CONTRACTOR
led
ADDRESS 7-A
CONNECTION DATA
CITY EL, NO. STATION DEPTH
LIC MANHOLE REFERENCE�
LICENSE NO. CLASS
STATE
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
E- "7Y
M.L.HOI S£SEWER CON htr_TING 70
_L
_t�UflLLC Y. --- ---CURB >_
_�EWER P.C.NO,
SEPTIC TANK,SEEPAGE Fir OR 3, D_
PITS AND/OR DRAINr;ELO CO.IMP. JOS No. 0
SE WER CONNECTING TRUNK PERMIT NO. ROAD PERMIT NO, u
IRIVATE DISPOSAL SYSTEMm
CONN CT ADDITIONAL BLDG.OR. AFFIDAVIT TwA1YFR
RE�
E lir)
O . NSTR NO DATE
WORK TO HOUSE SEWER 0
EI�'RFLCI-SEEPAGE PIT.DRAINFIELO
XT ..CF55POOL.DRYWELL.MAN40Li� Lu
9CGTCR"R>CTRYR'tTR ABANDON HOUSE HWY.OR ST.WIDENING
SEW R SYSTEM
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S J.14 ER'S P RMIT $
CONNECTION CHARGE FEE
AUTHORIZATION1 TOTAL FEE I L — —
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED LXLST'NG DWELLING
----
TO
orHE PUBLC SEW ESR.
APPROVAiS DATE I INSPECTOR'S SIGNATURE
SIGNED THIS—DAY
OWNER OR NEW HOUSE SEWER
OWNERS AGENT-- C'__ _JAL_ _'_'_'___
0NNECTADDlTONG
BUILDIN OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAIN F!ELD
A N D STATE THAT THF ABOVE iS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl ORYWELL [I
HEREBY CERTIFY 1-HAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIREO BY L02_",GLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT_i-*W HE LF A',_ OWNER OF, AND INTEND TO DIS CQNNECT PLUG AND
RESIDE $N_ T.-JE-AVOVE DZ&f-�_ _lRFSIDENTiAL P Rly ABANDON HOUSE SEWER
S i G NAT BACKFILL SEPTIC TANKS
OF E]
SEEP,PIT(5) CESSPOOLS ❑
VAPDATION
K. 111.D. CASH
r-NAR