HomeMy Public PortalAbout5444 MCCULLOCH AVE_Sewer__ SaE-6D • ' APPLICATION FOR FERE" IT �.
,DIVISION OF BUILDING AND SAFETY SEWED SEWAGE DISFC,,3AL
Department of County Engineer + .
County of Los Angeles BUILDING ' __ ✓
JOHN A. LAMBIE,COUNTY"ENGINEER _ADDRESS
J - CASSATT D.GRIFFIN, SUPT OF BUILOING LOCALITY f-
FOR. APPLICANT TO ILL IN NEAREST
-------------- CROSS ST.
LEGAL C.
DESCRIPTION LOT N0. OWNER ,.
MAIL
. BLOCK -^TRACT /_ _��rt� --------- 4DDRES5 ------'-- ------
IZE OF L ---------
NO. OF BLDGS. + CITY TEL.SOT .NOW OR,LOT
USE OF ------ - ---
BU,ILDINGS ' _ DISTRICT NO. GROUP .MAP
=— - - BK PG
CONTRACTOR
ADDRESS
STATION DEPTH J'
CITY _ - TEL.NO .-- ---- -L- < =-
.. '` � MANHOLE REFERENCE ✓ ;fir __
.LOWER ,.
REGISTRATION N0. __- ❑ COUNTY --
No. DESCRIPTIO F IN0 -K FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOCcv i --- - y CURB P,L' M.L,TO P.L.
-PUBLIC $3.b0 ---" "ems.--- '�= '— s --
SEPTIC TANK SEEPAGE PIT OR
PiTSAND OR_DRAINFIELD____ _ $3.00 ---- ---- --- - --_ -^- _
OVERFLOW SEEPAGE PIT DPP�iNF.IELII---( _:------- y -P C NO.
EXTN.,CESSPOOL,DRYWELL,KAN_HOLE C� $:.00( CO. IMP.NO._ _. -- _JOB N0.
.. HOUSE SEWER CONNECTING T6 - - ------ ------
PRIVATE DISPOSAL SYSTEM f� I _ _ ,
_{. $1.00 _ TRUNK PERMIT NO. ROAD PERfi!iTN0.
CONNECT ADDIT?ONA�BLDG.OR I STATE ENCROACHMENT --��- = --.
]--WORK TO HOUSE SEALER ce $1.00 _ PERMIT N0,
ALTER,REPAIR OR 'ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM �o� .$1.00
----� -- ----------- .�_ --- - - WASTE APPROVAL
�'�.--- -------..-_.._. CHARGES
CONNECTION CHARGE FEE
TT OWNER'S PERMIT --- $ 1. 00
AUTHORIZATION TOTAL FEF. � REIMBURSEMENT FEE '
I HAVE AT TH-iS DATE A CONTRACT WITH THE HEREIN fiMED CON. APPROVALS DATE {INSPEGTOR'ss1GNaTURE-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -`-- ---- ----- ,?-- -- -TO THE PUBLIC SEWER, f NEW HOUSE SEWER I - -
SIGNED THIS -DAl �' 19_--_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT- se � - -- SEPTIC TANK,SEEP,PIT($1 - t---- --�--
ADDRESSS. - AND/Oft DRAPNFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
CESSPOOL U DRYWELL:]
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALI. COUNTY ORDINANCES AND STATE. LA`n`S REGULATING ALTER REPAIR,SEWER OR I f
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AN",'O.R DISCONNECT PLUS'ANDLICENSED As AS REQUIRED BY LOS ANGE S COUNTY AND 5T OF ABANDON CT PLUG AND _
CALIFORNIA OR THAT I T.14 L WNER. OF THE ,. BOVE - - US--
DESCRIBED RESIDENT! 0 BACKFILL SEPTIC TANKS G]
SIGNATURESEEP. PIT IS,). L! CESSPOOLS❑
OF PERMITTEE
(
IOHN A. LAMBIE,COUNTY ENGINEER VALIDATION �ROBERT A, WOOD,CHIEF PLBG. INSPECTOR
CASH