HomeMy Public PortalAbout5436 MCCULLOCH AVE_Sewer__ '6A 642D-CE808- APPLICATION PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNE—AREST
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4l. •.�i.T it
FOR APPLICANT TO FILL IN VA,
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LEGAL
DES
CRIPTION LOT NO. OWNER i1 j,V �
MAIL ``r
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT - NOW ON LOT CITY " -} "fL'a TEL. NO,
USE OF
DISTRICT NO. GROUP MAP pR E55E0 BY
BUILDINGS _ 'f�d�,�,�X-. �yB�K''' PSS/J
CONTRACTORS i 7�,9,C, i c L' 1 / —/0 /
ADDRESS �C9ONNECTION DATA
CITY LJ :/,! 6'i' /STATION " DEPTH
EL.
STATEy)� j LIC �( /
LICENSE NO; �4 P GLASS '�-C- c, REFERENCE y . //,, LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION L+-'2 LENGTH V FROM
HOUSE SEWER CONNECTING TO Y. CURB r:f M.L.TO P.L.
PUBLIC SEWER 0 $7.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. CL
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIYER EASEMi xT. RECORD.iMSTR.NO. DATE 0
/ WORK TO HOUSE SEWER $3.00 Cf
OVERFLOW SEEPAGE PIT.DRAINFIELD _ ix
EXTN..CESSPOOL.DRYWELL. @ $5.00 HWY.OR ST.WIDENING O
ALTER.REPAIR OR ABANDON HOUSE - Ir-
SEWER OR
°SEWEROR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT ` >
Lu
PERMIT NO.
MANHOLE
$7.00 INDUSTRIAL
WASTEAPROVAL Z
WASTE APPROVAL
OWNEMS-1 PERMIT $ 31 00 CH RGES
AUTHORIZATION TOTAL FEE /C.7C/ J CONNECTION CHARGE 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 SEWE}Q APPROVALS DATE._.. INSPECTOR'S SIGNATURE
SIGNED THIS_ V DAY OF 19�`-"']7� -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL ]
BUILDING OR WORK
ADDRESS. - SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL 4
ID
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
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND -y
RESIDE IN, THE A �ESCRISEED BlrSIC NT"'IAL PR OPE RT ABANDON HOUSE SEWER ILL SEPTIC TANKS
SIGNATURE s / -y7 —_- -
OF PERMITTEE Y / _ BACKF ❑
SEEP.PIT(S) tigESSPOOLS ❑
VALIDATION 1: M.O. CASH
Ci int;l 9 1 O 0 6.0 0
6A 642D -CE808 -10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 111...111
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
S
. .'-sfi
a FOR APPLICANT TO FILL IN „/ ('
LEGAL
DESCRIPTION LOT NO. ,1 (.L
pW NER y/
BLOCK TRACT � J +'- E_ ADDRESS 7 '(- �/�'7p Ire
NO. OF BL GS,
SIZE OF LOT NOW ON LOT CITY ,/>'•°'" 'tL. NO.
USE OF
BUILDINGS__ DISTRICT NO. GROUP BK MAP Pa -' -�PROCESSED By
_ _
CONTRACTOR � �(� .'f
ADDRESS , .-/ r •_�f� CONNECTION DATA -_
7
TEL. NSTATION I�l,S DEPTH
CITY �� O. ��
STATE LIC I _ ta�R
�(5 /,�+ / MANHOLE REFERENCE
LICENSE NO.
' ', d CLASS LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.I_ M.L.TO P.L.
PUBLIC SEWER @ $7.00 —
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. iL
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAYIT I WAIVII I EASEMENT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD _
EXTN,.CESSPOOL.DRY WELL. @ $5.00 0
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 1-
SEWER OR DISPOSAL SYSTEM $3,00 _ STATE CROACHMENT u
EN
MANHOLE $7.00 PERMIT NO. C.
--- --- INDUSTRIAL N
'7I �+EN' 3 00 WASTE APPROVAL CHARGES Z
CI♦WS PERMIT $
ii
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE--- —
I 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
OWNER OR NEW HOUSE SEWER V _
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFfELD
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 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
CALIFORNIA OR THAT THE LEGAL OWfCF7O AND INTEND TO
RESIDE IN, THE ABO E D CRIBED 'YEN IAL ROPERTY. DISCONNECT PLUG AND
ABANDON HOU
llaSE SEWER
SIGNATUREy! y,
OF PERMITTEE W -� �c."F'+•' �L�` BACKFILL SEP71C TANKS ❑
SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK. M.0. CASH
8 7 5iY1 U W