HomeMy Public PortalAbout5602-5604-5606 MCCULLOCH AVE_Sewer__ 6A 642D — CEeo� — 9"3 APPLICATION O-OR PE'i—
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY -
FOR APPLICA�, TO FILL IN NEAREST _
GROSS ST, .c^
LEGAL J �
DESCRIPTION LOT NO. yf' �p OWNER
-�" �1 MAIL
BLOCK TRACT j {�f ADDRESS „a
OF OL US. �,,, -�[•! L
STYE OF LOT G '� p J `y'NOW ON LOT - CITY - TEL, NO. .d
USE OF
BUILDINGS -__ 4. DISTRICT NO. GROUP SK MAP Pa b6jr55ED BY
CONTRACTOR
ADDRESS 3 r CONNECTION DATA
CITY I STATION �� - •+. DEPTHTELNO. 094� - �-
STATE LIC 6• UPPER
z�'� MANHOLE REFERENCE -2
J�LLICENSE NO:: yam' GLASS -,- `t- _d✓° �pc�e jd0e L•+b+lrl7�•-s
No. I DESCRIPTION OF WORK FEE TYPE SOF CONNECTION LENGTH FROM ..>
HOUSE SEWER CONNECTING TO Y. CURB
PUBLIC SEWER $7.00 P �✓ M.L.TO P.L.
�E`+'i .-_-- �` P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $10.00 CO.-IMP.-NO. X.I ,j JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT WAIVE. EASE-1 RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 b� - d
OVERFLOW SEEPAGE PI'T.DRAINFIELD �
EXTN.,CESSPOOL.DRYWELL, $5.00 HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE '
SEWER OR DISPOSAL SYSTEM 0 $3,0_0 _ CD
STATE ENCROACHMENT 7
MANHOLE 0 $7.00 PERMIT NO. �' / W
---- INDUSTRIAL d,
WASTE APPROVAL rn
OWNERS PERMIT S a CHARGES O0 --
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE - -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEES���ii ,�
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS _�., t`”`
TO THE PUBLIC SEWER. E fNPIPECT04AV SIGNATURE'
fir
SIGNED THIS. DAY OF 19-
OWNER OR NEW HOUSE SEWER
OWNERS AGENT- +
CONNECT ADDITIONAL
BUILDING OR WORK '¢
ADDRESS._ -
SEPTICTANK,SEEP,PIT(S)
AND/OR
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
B
PLUMING AND 5EWERS. CESSPOOL ❑ DRYWELL ❑
i HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY'AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF'C,RN IA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL ROPE RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFELL SEPTIC TANKS ❑
OF PEARM *TT .P5�EEP..FiL (S) ❑ CESSPOOLS
VALIDATION, CK. M,O. CASH1 2 1 jut. 3.0 0 ,cvc
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