HomeMy Public PortalAbout5434 MCCULLOCH AVE_Sewer__ 6A 642D-CE808 -10-71
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY fyy"(0 7-"
FOR APPLICANT TO FILL IN NEAREST
CROSS 5T.
LEGAL
DESCRIPTION LOT NO. ! OWNER :I"� LJ•t .
-- MAIL �-
BLOCK TRACT ADDRESS x
NO. OF BLDG$. - - /wry
SIZE OF LOT NOW ON LOT CITY 1 TEL. NO.
NO. OF BLDG$. I&
USE OF
BUILDINGS DISTRICT NO. GROUP MAP -PR�CESSEO BY
BK PS b
GONTRACTOR
ADDRESS - CONNECTION DATA
-- - vr✓� C3 C-
We
-,,.. STATION p DEPTH
CITY TEL. NO.
STATE )''`J a+�, LIC y MANHOLE REFERENCE UPPER
LICENSE NO-. , j K /f CGLA55 �-�' .j„®yygyq-
NO. 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
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 510.00 CO. IMP. NO. JOB NO. 7
HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. ' Dom„
_
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1vla [As[M[Xr RECORD.INSTR.NO. O
DATE V
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD C4
EXTN..CESSPOOL,DRYWELL. SS.00 O
ALTER.REPAIR OR ABHWY.OR ST.WIDENING
ABANDON HOUSE 0
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT W
i.AANHOLE ----_ $7.40 PERMIT NO. (y
INDUSTRIAL N
WASTE APPROVAL z
CHARGES
OWNERS PERMIT S 3 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ,; I-
1 HAVE 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 I
OWNERS AGENT --� �
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING �y
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL LJ
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
Li_ENSED AS REQUIRED BY LOS ANGLES COU Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THl!T THE LEGAL OWN AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV DE CR18ED 1 EI(T AL ROPER Y/ ABANDON HOUSE SEWER
s
SIGNATURE j�f' y BACKFILL SEPTIC TANKS ❑
OF PER MfTT EE_ -F - -V
SEEP.PITS) ED
CESSPOOLS
T
VALIDATION CK, M.0. r' CASH
I'