HomeMy Public PortalAbout5528 MCCULLOCH AVE_Sewer__ DLWA.ISTAIENT OF COUNTY ENGn4`EER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I AUILDING
DDRESS 55Z„ j' ���
FOR APPLICANT TO FILL IN LOCALITY I C
BUILDING /r
ADDRESS,Mf �D� ����fj�.".C�-!'�, 1 CROSS ST.
LOCALITY w x HJ,LC DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST e �' A ' ��
CROSS ST.d� .,-w��
CEIVED BY Ready for Inspection ^` DATE ISSUED
OWNER `�� J'�_�'r .Gp.� , .A.MAIL
ADDRESS,�,S,'� /�6,i [� •1; USEZONE OCCUPANCY MAP
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CITY !1 TEL.NO. _ ' I OS9
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CONTRACTOR @ ;� •ja . 1' A
CO.IMP.NO. 133 _ 6
ADDRESS �� 'fir'�v 00.— _ ��,� JOB NO.
TEL.NOp s i' �
4�"�t�� C'�.1�F�� TRUNK PERMIT NO.
n
ATE
REGISTRATION NO. (f j),5; COUNTY ROAD PERMIT NO. 5 ��
DESCRIPTION LOT N0.S g0 [b SiD 9� ' , PERMIT ENCROACHMENT
BLOCK TRACT � � 0 'P �T3 INDUSTRIAL
IQ 0.OF BLDGS. WASTE APPROVAL
SIZE OF LOT d NOW ON LOT CHARGES
BSE
UILDINGStfyr �. - CONNECTIO A_RGE FEE
NO. DESCRIPTION OF WORK FEEy
POHOSE SEWER CONNECTING TO REIMBURSEMENT FEE� ,a
S SEWER 110 $ 3.50 RECEIPT NO. SA E_ BY
HOUSE SEWER CONNECTING TO '�+�
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.ORO EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE BY a
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
P TS ANPTIC D/OR�DRAINFIE DSEEPAGE IT OR 2A0 t
CESSPOOL—DRYWELL STATION 1 t a 00 DEPTH
SPECIAL CONDITIONS ONLY 2.001 �I MANHOLE REFERENCE
4
_ a Ct MEW LOWER
TYPE OF CONNECTIO LENGTH FROM
OWNERS 00
fri o to 1 M.L.TO P.L. 1
PERMIT ;
AUTHORIZATION TOTAL FEE /6 . v
IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS___.... —DAY O _ �;_19.._. NEW HOUSE SEWER ��f�).oG a R a
OWNER ORr� CONNECTADDITIONAL
OWNERS GENT. .. _ =..=.".:. s:_:...: BUILDINO OR WORK
�� r' SEPTIC TANK,SEEP.PIT(S)
ADDRE88..._. .._ 1.�w4„r_,� AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE D C/Ep_� ESIDENTIAL PRAPERTY. BACKFILL SEPTIC TANKS _
f SEEP.PIT(S)[] CESSPOOLS� SC 1 P � "
SIGNATURE � � x' � 9
OFPERMITTE c !% r�_'�"k�._Y.,
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