HomeMy Public PortalAbout5544 MCCULLOCH AVE_Sewer__ E808 5-65
6A 642r) APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _z
JOHN A. LANIBIE, County Elngineer ADDRESS
ng
COLEMAN W. JENKINS,Supt. of Huildi
LOCiTY
CROSS
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION _.OWNER
TR I A� MAIL
BLOCK TRACT ADDRESS
No BLDGS.
SIZE OF L
NO 0 LOT
NOWONCITY TEL. NO.
USE OF
FOR
LEGAL
_CR'PT t��
C�'
BUILDINGS DISTRICT NO. GROUPI MAPPG PROCESSED BY
BK
CONTRACTOR/
ADDRESS CONNECTION I
STATION DEPTH
CITY 4e�-X TEL. NO.
-7
LICE NS LICENSE �54;11ER
CLASS MANHOLE REFERENCE T LOWER
NO, _7
N... DESCRIPT11 _W_6F_VV76_RK FEE TYPE OF CONN.ECTION LENGTH FROM
SEWER CONNECTING TO Y. .L.TO P.L.
40_US E CURB P.L.P.L.
PUBLIC SEWER $ 5.00
SE PT I TAN JO*Nq�
RI TS N D OR DRAINFIELD $10.001 4 1" ��_/. CL
IMP.NO. 13, �kv
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Y
CO.C
MANHOLE N
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YL
P
IMP,
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0-USE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM, $ 3 00i TRUNK PERMIT NO. ROADPERMIT NO.
IF I. IT EASEMENT RE DATE
ONNECT WURK. TO AODII ONAL DLDG.
DC. OR t'A��FTo;A_V_7!vKR RECORD. INSTR.NO.
HOUSE EWER $ 3.00li
Ktl`Al� UR_XYXN_D6_N '4 OUSE
SEWER OR DISPOSAL SYSTEM $ 3.001
HWY.OR ST.WIDENING
$ 5.00 T T
EXTN.,CE.5SPOOL, MAN116LE CL
:;TATE ENCROACHMENT
A
PE
PE,
PERCOLATION TEST $ 5.00 PERMIT NO, z
WASTE APPROVAL CHARGES
OWNERS PERMIT 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 Z,� 4-
.1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE P UBLIC SEWER. DATE INSPECTOR'SSI
SIGNED THIS OF 19 APPROVALS 1,�4 _?NATURE
OWNER OR NEW HOUSE SEWER (706 be'4
W �R.AGENT T CONNECT ADDITIONAL
BUILDING OR WORK
AODFRESS�_j -SEPTIC TANK,SEEP,FIT(S)
NEW
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
Pl_U MB ING AND SEW E RS. 'CESSPOOL [I DRYWELL ❑
I HEREBY CERTIFYR,,iiALT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RE8Y LOS ANGLES COUNTY AND STATE 0,F SEWAGE DISPOSAL SYSTEM
CALIFORNIA C- 'THAT-T I AM THE: LEGAL OWNER OF, AND INTEND TO
DISCONNECT PLUG AND
RESIDE IN.,,THE XBO�X DESCRIBED R.F,6IDE�14AL PROPERTY.
ABANDON HOUSE SEWER
I
SIGNATU R"k BACKFILL SEPTIC TANKS ❑
OF FERNITTEE
L SEEP.PIT(sj E:l CESSPOOLS ❑
VALIDATION
CK. q M.-. CASH
�J D
7.0 C)-
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-E8O8 5-65 I've IIJ
76AG42D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
1011'i A. Flngino('r ADDRESS 116 c,
COUMAN tk S,3p't. of Building —7—
LOCAL;TY
N
FOR APPLICANT TO FILL IN _CROS-R ST. A
LEGAL—
DESCRIPTION IN 011A� ' ✓ OWNER' 4
COT
MAIL
BLOCK ,BRACT
ADDRESS 7
NO. OF SLOGS.
SIZE OF LOT X NOW ON LOT CITY TEL. NO.
-- — -- .------- ——---- -- /4--��C f , I--'� '� C�
SE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
P
BK G
CONt
TRC
-ACTOR
ADDRESS CONNECTION I
NO.
, I"
STATION
DEPTH
' --
LICENSEC�NSENo. C-ASS MANHOLE REFERENCE
NO, DESCRIPTION OF WORK
FEE TYPE OF CONNECTION LENGTH FROM
HOU�E s�EWER co-w4�Fc�nwG Y CURB P.L. M.L.TO P.L.
PUBLIC SEWER $ 5.00
4SEPTIC I J,PC 4 N NO rL
�
PITS AND OR DRAINFIELD $1 0.0o CO. IMPNO. 1 0
HOUSE SEWER CONNECTING TO u
VATE DISPOSAL SYSTEM 3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
PRIix
AFFIDAVIJWAIVEREAsEMENT RECORD. INSTR.NC;—T--DATE
--
-TWORK TO HOUSE SEWER $ 3,00, 0
R WA13ANDQN-14�USff-----
R �j
SE R OR DI SP05AL SYSTEM $ 3.00 u
L Lu
HWY.OR ST.WIDENING
SPOOL, MAN _LE $ 5.00 ------------
----I ____ _---------------1 STAz
PERCOLATION TEST $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2" 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TO CONNECT
TRACTOR THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC
SEWER. DATE DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
4Z
OWNER OR NEW HOUSE SEWER
'
OWNERS AGENT1 2
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
...........
..........
SEPTIC TANK,SEEP,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND!OP DRAINFIELD
A No STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY —-----
WITHALL COUNTY
ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [I DRYWELL ❑
IHEREBY 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
CALI f.ORN(A OR THAT I API'THE LEGAL OWNER OF, AND INTEND) TO
S DISCONNECT PLUG AND
RE"ID E IN, THE ABO,VE/PESCR(BED RESIDENT ALL:PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF FERMI EE BACKFILL SEPTIC TANKS ❑
TIT
SEEP,PIT(5) ❑ CESSPOOLS E]l
VALIDATION
CK. M.O. CASH
C, D
7.