HomeMy Public PortalAbout5616 MCCULLOCH AVE_Sewer__ E80APPLICATION FOR PERMIT
6A 642D2D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION suILOING ,,r �
IOHN A, LAMBIE' Ceun(Y Engineer
ADDRESS L }s 'I r
WILLIAM A. IENSEN, Sup"(of Building LOCALITY
NEAREST
FOR APPLICrANT TO Flit. IN CROSS ST.
LEGAL OWNER .T -
DESCRIPTION LOT NO.
BLOCK TRACTi MAIL
ADDRESS C . e'..�-c �'z... ':'.4'1%
140.OF BLDGS. f
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO., GR0 NAP PROCESSED BY
BUILDINGS ° - BK P6
CONTRACTOR
ADDRESS CONNECTION DATA
CITY +/ TEL.NO. `', y r fr S T' N ( �- DEPTH
REGISTRATION N0. « ` f 8 STATE MANHOLE REFERENCE _-
COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEINER CONNECTING TO ) L.p" r
PUBLIC SEWER S3,00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CUR , P.L. M.L.TO P.L. -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DR
AINF'1€LD 0.
HOUSE
l , . d
EXTN,.CESSPOOL.DRYWELL $2.00
HOUSE SEWER CONNECTING TO i y P.C.NO. 0
PRIVATE DISPOSAL SYSTEM @° $1,00 CO.IMP,N0, T JOB N0. u
WORK TOTHp 3EISENER LDC.OR C $I 09 TRUNK PERMITHO. ROAD PERMIT NO. fx
O
S'WER OR DISPOSAL OR ABANDON HOUSE @ $1.00 STATE ENCROACHMENT I-
PERNIT NO. U
W
INDUSTRIAL 9L
- WASTE.APPROVAL
CHARGES _
Owmirs PERMIT S 2! 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE j c'- REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE HEREIN NED Com-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELL NG APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OP,�— 19— NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
OWNERS AGENT--.-- s',rC' BUILDING OR WORK
ADDRESSSEPTIC TANK,SEEP.PIT($)
- AND/OR.DRAINFIELD
LHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL C7 DRYWELL
H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
MBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
ENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
lF'ORNIA OR THA IAM THE LEGAL OWNER QF THECRIBED RE5IDENT L ROPERTY. BACKFILL SEPTIC TANKSNATURESEEP.PIT(S CE5SP60L5 PERMITTE L v f., -
VAIMATION-' ROBERT A. WOOD
CK, X.0. '"CHAR SUPERVISING MECHANICAL ENGINEER
li
A64 APPLICATION FOR PERMIT
�€A642.D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
1014N A, LAMBIE, County Engineer ADDRESS
���
WILLIAM A, JENSEN, Supt ®i Building LOCALITY
FOR A€is PUCANT TO FELL IN
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACTr MAIL
+' H ADDRESS
N0.OF BLDGS.
SITE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS '� DISTRICT NO. GROUP I MAP PRQCES a,By
CONTRACTOR eIBIC P6
`v."'.�. V� s ` ;'fir C. {. - .
-J-
ADDRESS t-, y p C®NN>bCTION DATA
CITY 7EL.ND.,L 2* 4»+ AT N o '--�� `� DEPTH
1
REGISTRATION N0, Y 2 ® COUNTY MANHOLE REFERENCE ' 4i. �+ 3 ."'�~- LOWER r.
NSTATE
O tSESCRIPTION OF WO
r FEE `
HOUSE SEWER CONNECTING TO ff
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB - P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD a
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO '3 P.C.NO. O
PRIVATE DZSPOSALSYSTEM @ $I.00
JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0,
WORK TO HOUSE SEWER C $I.00 1
ALTER,REPAIR OR ABANDON NOUS€ STATE ENCROACHMENT
5EW OR DSP L SYSTEM @ $1.00 _ PERMIT N0.
INDUSTRIAL -
WASTE.APPROVAL
RBS
CHARGES z
OWNER'S PERMIT CONNECTION CHARGE FEE
THORIZATION TOTAL FEE } y> REIMBURSEMENT FEE
VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
E PUBLIC SEWER.
ED THIS DAY OF 19— NEW HOUSE SEWER
R OR 2'7
CONNECT ADDITIONAL
RS AGENT nom' y--'� BUILDING OR WORK
°SS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD i
:REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
i
TATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
ALL, COUNTY ORDINANCES .AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
ING AND SEWERS. SEWAGE DISPOSAL.SYSTEM
2EBY CERTIFY THAT I AAI PROPERLY REGISTERED AND/OR "A6iY"
DISCONNECT PLUG AND
:D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
RNIA OR THATI AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
1/p BACKFILL SEPTIC TANKS
URE -
BED RESiDENTtyAL ROPERTY. � I�
f SEU.PIT(S) E] CESSPOOLS
' �
J VALIDATION ROBERT A. WOOD
CK, M.0, ,` CASH SUPERVISING MECHANICAL ENGINEER