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Home My Public Portal About5628 MCCULLOCH AVE_Sewer__ 1 / f 650 14,44S-' f,r CE808 7sAs szC142D-60 APPLICATION FOR P RMIT - COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION Bu1tDING ADDRESS f�✓ /'/v i-�- IOHN A. LAMBIE, County Engineer WILLIAM JL JENSEN. Sup'i of Building LOCALITY NEAREST �. FOR APPLICANT TO FILL IN1__�qrioss ST. LEGAT OWNER DESCRIPTION LOT NO X1...4 s ft.k_ " s BLOCK TRACT :L MAIL ADDRESS SIZE OF LOT NOW ON LOTS CITY TEL. NO. USE OF r BUILDINGS c DISTRICT NO. GROUP BK MAP PG PROCESSgD BY CONTRACTOR I_ f" a ADDRESS tt CONNECTION DATA CITYTEL.NO iON '-, _ DEPDEPTHc - �,: -T'ATE MANHOLE REFERENC ' -UPPER REGISTRATION NO. �'V COUNTY •9�J k N0. DLaCR!PT!ON OF WORK T FEE'S HOUSE,SEWER CONNECTING TO PUBLIC SEWER (0) .$3.04 ' TYPE OF CONNECTIONt• LENGTH FROM, SEPTIC TANK,SEEPAGE PIT OR � Y, CURB P.L. M.L.TO P.L. PITS AND/OR DRAINFI_E_LD $3.00 OVERFLOW SEEPAGE P;T..'JRAINFIELD '..:_ EYTN.. CESSPOOL.DRYWELL C> $7_,00 _ 'Y - HOUSE SEWER CONNEC'T'ING TO CO. IMP. N0. � JOB NO. � . PRIVATE.DISPOSAL SYSTEM @ $1.00 M CONNECT ADDITIONAL.BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO.;'- '® WORK T'0 HOUSE SrVJE,ft @ $1,04 U ALTER,ktPAIR OR ABANDON HOUSE STATE ENCROACHMENT eq SEWER OR DISPOSAL SYSTCM $1.00 PERMIT NO. O INDUSTRIAL U WASTE APPROVAL CHARGES - OWNER'S PERMIT s 2 i 00 CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE �e ".- ` REIMBURSEMENT FEE I- HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. " f i : - ' SIGNED THIS DAY OF__� 19_._ NEW HOUSE SEWER I _ OWNER OR ` CONNECT ADDITIONAL OWNERS AGENT .� BUILDING OR WORK I ADDRESS SEP71C TANK,SEEP.PIT(S) RR AND/OR DRAINFEELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑_�� WITH ALL CO dTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR PLUMBING AN SEWERS. SEWAGE DISPOSAL SYSTEM _ 1 H`:REBY ERTlFY THAT I AM PROPERLY R GlSTERE'D AND/OR DISCONNECT PLUG AND LICENSED RE (JIBED BY LOS LES COU TY AND STATE Of ABANDON HOUSE SEWER CALL '7RNt 0 HAT I AM THE L L W. E;R°" THE ABOVE BACKFILL SEPTIC TANKS Cl DESCRtB.ED E 1DN dAL PRUP6RTY. ��L--A r` SEEP. PIT(S) ❑ CESSPOOLS., ] SIGNATUR < 1 OF PER TTEE r- - �F VAIMATIO / ROBERT A. WOOD CK. M.o, icksR SUPERVISING MECHANICAL ENGINEER 24650'INSE$T�, j 6A 7642.ea APPLICATION FOR PE'�i/MIT , EiAS 4213 COUNTY OF LOS ANGELES SEWER---SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING y/� ADDRESS ! �".. IoPiN A, );AMBLE, County En insor WI:.Y%AM A. JENSEN. Supt of Building LOCALITYNEAREST - r FOR APPLICANT TO FILL: IN CROSS ST. - - i' �' LEGALp' r fi DESCRIPTION LOT NO(' r �' _ ,v MAIL BLOCK TRACT };✓ f ADDRESS NO OF BDGS, SIZE OF LOT NOW ON LOT �� CITY TEL, NO. USE j d DISTRICT N0. GROUP BUILDIDI NGS`'_ BK MAP PG PROCESSp F %,BY CONTRACTOR � ADDRESS �� ,r" COWNECTION DATA CITY TEL.NO. a �,`Of TION y _-'s DEPTH y° STATE MANHOLE REFER ki r UPFFR'r REGISTRATION N0. COUNTY ' NO. DESCRIPTION OF ORK FEE HOUSE SEWER CONNEifTING TO PUBLIC SEWER $3.00 I 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 Fx'rN .CESSPOOL. DRYWELL @ $2..00 HOUSE SEWER CONNECTING TO . , P C NO, PRIVATE DISPOSAL SYSTEM @ $1.00 CO, IMP NO. + - / JOB N0. CONNECT ADDITIONAL BLDG.OR i TRUNK PERMIT N0. ROAD PERMIT N0. WORK TO HOUSE SEWER @ 31.00 I ALTER, R,,PAIR OR ABANDON HOUSE -STATE ENCRDACHMENT SEWER OR DISPOSAL SYSTEM C% $9.00 PERMITNO. ®. -' 0 INDUST'RIAL Zy }— WASTE APPROVAL 1+3 CHARGES O RAS PERMIT ';. CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR. TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. - - -- SIGNED THIS—DAY T 19— NEW HOUSE SEWER OWNER OR > CONNECT AOD1T[QNAL OWNERS AGEN' BUILDING OR WORM. ADDRESS. SEPTIC TANK,SEEP.PITS) - -- AND/OR DRAINFIFLD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL i-J DRY`XELL ❑ WITH ALL COU TY ORDINANCES AND STATE LAWS REGULATING ALTER,.REPAIR.SEWER OR PLUM9(NG AND EWERS.. SEWAGE DISPOSAL.SYSTEM I HE RTIFY THAT i AM P RLY REG11TERED AND/OR Z DISCONNECT PLUG AND LICENSED REQUIRED BY LOS ANEL COU, TY AND STATE OF ABANDON HOUSE SEWER CALIFORNZflkll `f{AT I AM THE L L 0W ER 0 THE ABOVE BACKFILL SEPTIC TANKS U DESCR"FEN. IAL PROPERTY,SIGNATOR gSEEPPITS) Cl CFSSPO2L MTEE _ .1� ,t i'7_77 .s-- ?'�-F DF VALIDATION—, ROBERT A. WOOD CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER 5.L. Iii 2 _ ,4 F