HomeMy Public PortalAbout5621 MCCULLOCH AVE_Sewer__ 76AU420
CE808 11-57 APPLICATION FOR PERN41T
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A. LAMBIE, County Engineer 5621 _',1L',u110c'1h, Avewi
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CASSATT D. GMFFIN. Sup't ci Building
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LOCALITY
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�,FNEAREST
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FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO, 16 OW ER I c'_f1s, IL"U,C t-1 Jl_on. �C"c'
BLOCK TRACT MAIL
Dn"7",U Llov,,er Azusa Road
ADDRESS
NO.OF BLDGS.
'-, !-� -
SIZE OF LOT NOW ON LOT CITY C,ri TEL,No. Gi 3'
USE OF 'Z I I
BUILDINGS DISTRICT NO. GROUP MAP
PG
CONTRACTOR .-i..r2,1
' 1 -1-
--.1 i a 17
ADDRESS - - CONNECTION DATA
_Z'
STATION DEPTH
r -JEL NO.
CITY a k: c�_1.
II STATE.
MANHOLE REFERENCE
REGISTRATION N0. COUNTY
I A�
NO. DESCwpm OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTILENGTH FROM
PITS AND/OR DRA!NFIELD rw $3.00 Y. CURB P.L. M,L.TO P.L. 6
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO,
PRIVATE DISPOSAL SYSTEM @ $1.00 co.IMP.NO. JOB NO,
CONNECT ADDITIONAL BLDG.OR
WORK TG HOUSE SEWER a $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEMi $1.00 STATE,:ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL CHARGES
OWNER'S PERMIT 5 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE i515-0
REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS 111T 51,tNATURE
TO THE PUBLIC SEWER.
SIGNED THIS —DAY OF------I 9— NEW HOUSE SEWER
OWNER OR 1"T CONNECT ADDITIONAL
OWNERS AGENT --BUILDING OR WORK
ADDRESS— SEPTIC TANK.SEEP,FIT(S)
AND/OR DRAIN51ELD
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[] DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE Of AIR, SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND,
CALIFORNIA OR THAT I AM THE. LEGhL OWNER OF THE ABOVE _.$BANDON -5 SEWER
HOUSE EW R
DESCRIBED RESkDENTIAL,,PROPERTY, BACKFILL SEPTIC TANKS
SIGNATURESEEP. PIT(S) [I CESSPOOLS 0
OF PERMITTEE
VAUDATION ROBERT A. WOOD
CKM.0. CASH SUPERVISING MECHANICAL ENGINEER