HomeMy Public PortalAbout5630 MCCULLOCH AVE_Sewer__ Cc A6 0 APPLICATION FOR PERMIT - l
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COUNTY OF LOS ANGELES EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
.BUILDING AND SAFETY DIVISION BUILDING �°
gqOFIPI A. LAMBIE, Countg En nncer ADORE S$ " e,l'A"/�
WILLIAM A, JENSEN, Supt of Building LOCALITY
NEAREST -�
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL. f i,,' �—^^- � �/f OWNER
DESCRIPTION LOT NO.�., e
BLOCK TRACT :�,. _- 'y:.— MAIL
DORESS
r
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. HO-
USE OF r'
BUILDINGS - _ DISTRICT NO. GROUP MAP PROCESSEVBY
IlK PG ° 'f
CONTRACTOR ;r''_. ""'C., i^•,�,� f k�.`�. ` �,,
4 rs gy
ADDRESS _ ,�' - CONNECTION DATA
CITY _ 51 TEL.N0. f - §T 'LION '.`DEPTH y
r �^ STATE MANHOL,E REFERENCE -. - �� ✓,; -'(-7PP£R_
REGISTRATION NO. Y COUNTY
[ALTER,
DSCftfPT;C�N 0� FEE
USE SEWFR CONNECTING TO
BLIC SEWER @) $3.00 +' TYPE OF CONNECTION - LENGTH
P71r TANGS SEE PAGE PIT'OR Y. CURB P.L, M:L.
TS ANDiOR QRAtNF'IELD @ $3.00 -
ERFLOW SEEPAGE PIT,DRAINFIELD
7`N..CESSPOOL. llRYWELL @ $2.'>0
USE SF':,SER CONNECTING TO r ' P.C.NO,
IVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0, JOB NO.NNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD.PERMIT N;/f U
RK TO HOUSE SEWER C $1.00
REPAIR OR ABANDON HOUSE STATE ENCROACHMENT�,ER OR Di SPO SAL SYSTEM $1.00 _PERMIT N0. OF
INDUSTRIAL U
WASTE APPROVAL
CHARGES to
O Z R'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FSE REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGTH THE HEREINAMED DWELLING APPROVALS { DATE INSPECT'OP'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA LSF` �19T NEW HOUSE SEWER �I
OWNER OR p;,.s CONNECT ADDITIONAL
- OWNERS AGENT__� BUILDING OR WORK
ADDRESS SEPTIC TANK:SEEP,PIT(S)
-- AND/OR DRAINFIELD
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL CI
WITH ALL COUNTY ORDINANCES AND STATE LAWS- REGULATING ALTER.REPAIR.SEWER OR
PLUMBING AND SEWERS` SEWAGE DISPOSAL SYSTEM
I HEREBY CERT( Y .HAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUF,AND
LICENSED A5 REOI. D BY LOS ANGELES COUNTY ND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR T I AM THE LEGA-b' OWNER THE ABOVE
DESCRIBED RESID I PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ' SEEP.PIT(S). L) CESSPOOLS
OF PERMITTEE
�eROBERT A. WOC(D
VALIDATION
CK. 1G.O. CASH SUPERVISING MECHANICAL. ENGINEER
�
24650 INSERTS h
`` 6 ° APPLICATION FOR PERMIT ry
78A842D 42D - COUNTY OF LOB ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING _
BUILDING AND SAFETY DIVISION ADDRESS- r�1:3
VVI IAY3.A.JEENSEN Supt o Bu lding
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. ,�'
LEGAL
DESCRIPTION LOT NO. ,+ ✓- _OWNER :
BLOCK TRAC7 r"r- w - MAIL
ADDRESS
NO.OF FLOGS. 't+
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS �w~,r �!,:�,,/,;=s'„✓, F+'.y� ,,r.;' DISTRICT NO. GROUP BK PG MAP PROCESSES BY
-- '
CONTRACTOR �+'" -y ,..�—•� o � 'r� _
ADDRESS ° CQNNECTIQN DATA '
CITY TEL.N0. t' ATION " ei'' DE_ P '
RT "� `y CSTATE OUNTY MANHOLEREFE.RENCE.w '� ,f' n i—'� .UPPER
_G_1_MATjON NO.
N0. I DESCRIPTION OF W_RC�— FEE
HOUSE.SEWFR CONNECTING TO
PUBLIC SEWER CO $3.00 TYPE OF CONNECTION LENGTH FROM -
P>
SEPT!C TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/011 DRAINFIELD @_$3.00
OVERFI-Ok7 SEEPAGE PIT, DRAINFIELD
E"kTN., c.ESSP00L,DRflIE:�L gal
HOUSE.S9 SER CONNECTING TOP.P.C.NO.
PRIVATE.D! POSA3 SYSTEM @ $1.00 `CO. IMP. NO, 3'� ,� JOB NO. y,
�ICONNECT AD'll i()N„L SLOG,ORa'
WORK TO HOLSE SEWER C? SI.O� TRUNK PERMIT NO. ROAD PERMIT NO. "��.. _e O
ALTER, KFPA R OR ABANDON HOUSE - U
S WFR OR DISPOSAL SYSTEM $1.,06 STATE ENCROACHMENT a
PERMIT 110. H
INDUSTRIAL U
WASTE APPROVAL W04
CHARGES En
Ow ERAS PERMIT " CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �3 x;, 1 + � 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 DAX OFA 19_ NEW HOUSE SEWER
OWNER OR ,�"`y g�" C CONNECT ADDITIONAL
OWNERS AGENT .��" t�' DUILDING OR WORK
ADDRESS-_ _ SEPTIC TANK,SEER.PIT(S)
-- AND/OR DRAINFIELD
I HER.EBYI 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 ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS WIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
HOUSE SAND I
CALIFORNIA THAT I AM THH""'L° GAL OWNER OF THE ABOVE ABANDOBACKFILL SEPTIC TANKS
DES Cl;16ED SI �;NT1AL PROPERTY. ❑
SiGNATUR
�, SEFP.PIT(S) !.J CESSPOOLS
OF PFR ITT. � t� �
VALIDATION' ROBERT A. WOOD
Cs, M.0. CASH SUPERVISING MECHANICAL ENGINEER