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HomeMy Public PortalAbout5510 MCCULLOCH AVE_Sewer_5/27/1975_ 76A642D .E 808(REV.617'11s APPLICATION FOR PERMIT PI SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR R APPLICANT TO FILL IN S DISTRICT NO. dGROUP AlMocEss o ADDRESS /'T 4.j h: �.J �"' •,_ �O'� { LOCALITY , i r CONNECTION DATA NEAREST ) STATION DEPTH CROSS ST. - �t{ J UPPER _ t MANHOLEREFERENCE LOWER TYPE OF CONNECTION LENGTH FROM MAILy ,J/_ Y. CURB P.L. M.L.TO P.L. ADDRESS (/ `' 4= l._--=- P.C.NO. CITY ��.� TEL.NO. �"� %3 ,. / CO.IMP.NO. JOB NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO.I DATE BLOCK TRACT NO.OF BLDGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS rl�♦ Imo, STATE ENCROACHMENT �/ R �ry PERMIT NO. CONTRACTOR © 6V/• 6 p 1. (�..-P /'�. INDUSTRIAL ,I /'��^ ^ /�- WASTE APPROVAL ADDRESS / V I �-` d L-�4' ` 4r r' CHARGES CITYTEL.NO. jqt/3 CONNECTION CHARGE FEE STATE LIC. REIMBURSEMENT FEE LICENSE NO. CLASS NO. DESCRIPTION OF WORKO FEE APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER O ITS AND/OR DRAINFIELD HOUSE SEWER CONNECTING TO BUO NNECT AL LD NG OR WORK S PRIVATE DISPOSAL SYSTEM • , e SEPTIC TANK,SEEP,PITS) CONNECT ADDITIONAL BLDG.OR - _ AND/OR DRAINFIELD WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL a DRYWELL EXTN.,CESSPOOL,DRYWELL.MANHOLE ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS,I] SEEP,PITIS)❑ CESSPOOLS J OWNER'S Permit s AUTHORIZATION f TOTAL FEE I e VALIDATION I HAVE AT TH15 DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ OWNER OR OWNERS AGENT ADDRESS 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WRH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE- SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. I. SIGNATURE OF PERM ITTEf. ti+t"♦r- 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY ' NEAREST FADDRESS OR APPLICANT TO FILL IN CROSS ST. ,..+ LOT NO. 'y" OWNER MAIL OF BLDGS. TRACT L,.7�-'_ w-•"'r ADDRESS T .. ,/'"� NOW ON LOT CITY TEL. MO. - DISTRICT NO. GROUP MAP PROCESSED BY SK PS R �.�._"�J, .-__ ^t. ..ey /,__._ CONNECTION DATA `-. STATION " + i i.„;,�jEPTtI CITY TEL NO.� i r_ F _ x x; ) i.,a. STATE LIC LICENSE NO, -- CLASS _ MA 04 E REFERENCE,, r. r •'COWER' No. I DESCRIPTION OFF WORK FEE 'O'�—"-�--�'` TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO T _ Y..- CURB P.L. M.L.TO P,L. PUBLIC SEWER @ $7.00 Y SEPTIC TANK,SEEPAGEPIT ORP.G.NO. PITS AND/OR DRAINFIELD $10.00 Co.IMP.NO. / _ -, / JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.C' PRIVATE DISPOSAL SYSTEM $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WMv[[ [A[[N[NT RECORD.INSTR.NO. DATE ,f WORK TO HOUSE SEWER $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD CD EXTN.,CESSPOOL.DRYWELL, S5.00 ALTER. -- EPA{R OR ABANDON HOUSE HWY.OR ST,WIDENIN R �-� �` d;E- .-.. W-'/�y �✓ � SEWER OR DISPOSAL SYSTEM $3.00_ STATE ENCROACHMENT O MANHOLE $7 OO PERMIT NO. C_') W '— - INDUSTRIAL Q,. WASTE:APPROVAL GO CHARGES � OWNERS PERM ff s a 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE I HAVE AT 'PHIS 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 OWNER OR - --- NEW HOUSE SEWER CONNECT OWNERS AGENT - '--�— - ----- ADDIYIONAL 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 ❑ 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 CA LI FCRNIA OR THAT I AM LOS LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DE SC RO BEO RES IDENT�A!_ PROPERTY. ABANDON HOUSE SEWER S!GNA7URE OF PE4?MffTEE BACKFILL SEPTIC TANK .=❑ -" SESEEP.PIT(5) y�}' CESSPOOLS ❑ VALM ON ) CK. M.O. CASH 6q f .J 'gr 47 i. ';J I] I v'.` i ✓ Via`. � 3 i 6A-„42D - CE808 - 9,,73 APPLICATION FOR FlEtI IIIT COUNTY OF LOS ANGELES -SEWAGE DISPOSAL. DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION AUILoIr;y ADOREE S T iTY ST FOR APPLICANT TO FILL IN T LEGAL — �-_ ----- DESCRIPTION LOT NO, O NFi+ M , BLOCK TRACT SIZE "OF LOT L NN LOT - C'r TEL. NO USE OF f:+'` .DIS-.RICT NO. GROUP MAP `PROCESSED BY BUILDINGS F - _ BK p5 CONTRACTOR ADDRESS -_ � > r +` r f_�.. ,.. CONNECTION DATA •, ,;'�F �.., _..._,+. TEL. NO'., STATION DEPTH STATE LIC! MANHOLE REFERENCE UPPER LICENSE NO,. CLA,,S .��p i,'',WS LOWER No. DESCRIPTION OFWORKF£F TYPE OF CONNECTION LENGTH FROM HOUSE SEWER.CONNECTING TO --T Y. CURB P.L. M.L.TO P.L. PUBLIC SEWER '- $7.00 P.C.NO. SEPTIC TANK.SEEPAGE PIT OR PITS AN.DI OR GRAINFIELD d $I<+.00 CO. IMP,NO. JOB NO. y HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. / PRIVATE DISPOSAL SYSTEM $9.00 CONNECT ADDITIONAL BLDG.OR -t AFFIDAVIT WAIVER 141,71T RECORD.iNSTR.NO. DATE } WORK TO HOUSE SEWER $3,00 OVERFLOW SEEPAGE PIT.GRAINFIELD O E%7N.,C E55POOL.DRYW ELL. a5.00 -- WIDENING OR ST. ALTER,REPAIR OR ABANDON HOUSE HWY. SEWER OR DISPOSAL SYSTEM f $9.00 ._ STATE ENCROACHMENT �- MANHOLE $700 PERMIT NO. C INDUSTRIAL C+.. WASTE APPROVAL N -T - �� �� CHARGES Z OWNER'S PERMIT $ ea CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE ` ' r�ILL,` -- 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C_ON- REIMBUREilEME,pN�T Fr. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE -INSPECTOR'S SIGNATURE SIGNED THIS DAY OF_ 19 OWNER OR --- NEW HOUSE SEWER OWNERS AGENT- CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL C7 DRYWELL ❑ PLU Mel AND SEWERS. _ _ _ _ I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR - LiCEN.SED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFC,RN IA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE ' OF PE&MTTTE£ r-'. '�`- BACKFILL SEPTIC TANKS El '— SEEP.PITS) -- CESSPOOLS ❑ VALIDAION CK. M.O. CASH