HomeMy Public PortalAbout5520 MCCULLOCH AVE_Sewer__ oj,
6A834$C? APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BIJ?LDING
N
ADDRESS'
,01IN A. LAMBIE, County Engineer
WIMLIAM A. IENSEN, Supt of Building
LOC,AL)TY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN
DF
NO.
LW OWNER
- 2-
MAIL
BLOCK ADDRESS
NO. OF 81_03 .
SIZE OF LOT "IV ON 51LOT CITY TEL. NO.
USE a,
DISTRICT NO GROUP MAP F`ROCESSED By
UK PC
CON,;RACTOR
ADDRESS CONNECTION DATA
STATION
TY i TEL.I No.
UPPER
REGISTRATION NO ve COUNTY MANHOLE REFERENCE
NO, DESCRIPTION OF WORK TYPE OPCONNECTiON LE'NG'TH FROM
OUSE SEWER CONNECTING
TO �-.�ry /Y., CU19B L, M.L.TO P��.X-"
H
-I- PUBLIC SEWER @ $5.00 '4
PI-T-6,R------ P.C_NO.
_-1SEP71C TANK,SEEPAGECO,IME NO. JOB NO.
R DRAiNFIELD @
_4 PITS-AND/OR _SIO00
HQ .5F,SEWERCONNECTING'TO
TRUNK PERMIT NO, ROAD PERMIT
U NO.
PRIVATE D�SPOSAL SYSTEM $3.00
T_A5DJ_ p,icb-"-b.—'NsiR. NO. iY—DATE
C ONN EC f ONWIL SL OR —-
WORK TO HOUSE SEWER $3.00
I&XTN.,CESSPOOL,DRYWELL,MAN HOLE 4' $5.00
HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISF19SAL SYSTEM6 .G.
STATE ENC H,I EWT
PERMIT'NO.
RI_A_L_________
WASTE APPROVAL
CHARGES
OWNEWS RMIT 2100
CONNECT-ON CHARGE FEE
AUTHORIZATION TOTAL jii
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORT J C ONNECI .ABOVE 0VE DESCRIBED EXISTING DWELLING
TO THE PUBLIC
UBLFC SEWER. .APPROVALS DATE 1INSPECTOR'S SIGNATURE
SIGNED THIS----DAY
OWNER OR NEW HOUSE SEWER
OWNERS
CONNECT ADDITIONAL
ADDRESS 8-0iLDiNG OR WORK
SEPTIC TANK.SFLP,PIT(S)
I H9AL
FRFY CKNOWEDGA
E THT 1 HAVE READ THIS APPLICA-ION .AND/OR
DRAINFIELD
ANO
N G STATI, THAT THE ABOVE !S CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL F-1 DRYWELL E-1
IHEREBY THAT I AM. PROPERLY REGISTERED AND/OR ALTI.R,REPAIR,SEWER OR
L�._ NS�,_DAS REQi-JIRFD BY OS ANGLES COUNTY AND STATE OF E.SEWAGDISPOSAL SYSTEM
C A L"1'CRN RN I A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO I S�'- NNF- CTP--LUG-AND
RESIDE IN. THE. ABOVE DESCRIBED RESfDENTI�,L PF�qPERTY. A5ANDON HOUSE SEW
Ell
SIGNA7URE ------
BACKFILL SEPTIC TANKS ID
BEEF,PIT(5) ❑ CESSPOOLS
2
,,`--,VALIDATION ROBERT A. 10 OOD
SUPFRVISiNG MECHANICAL ENGINEER
C K. W O. CASH
7