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Home My Public Portal About9016 BROADWAY_Sewer__ 'eASSKD APPLICATION FOR PERMIT eaoe,a-Ke COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1` DEPARTMENTG COUNTY ENGINEER BUILDING SAFETY DIVISION BUILDING ADDRESS InIOFRi A. LIE. Couvly EneaCASSATT D. FIN. Sup.I of Building LOCALITY WMEmmNEAREST FOR APPLICANT TO FILL IN CROSS ST, LEGAL DESCRIPTION LOT NO. OWNER BLOCK TRACT MAIL ADDRESS NO.OF BLD GS. , 0��j SIZE OF LOT NOW ON LOT CITY TEL. N0. i USE DI DISTRICT NO. GROUP BK MAP PROCESSED BY BUILDINGS \ J CONTRACTOR / P� ADDRESS / CONNECTION DATA CITY TE L.NO. /� STATION DEPTH STATE MANHOLE REFERENCE / U REGISTRATION NO. COUNTY LOWER N0. DESCRIPTION OF WORK EE HOUSE SEWER CONNECTING TO c PUBLIC SEWER (� E3.00 TYPE OF CONNECTION ENGTH FROM / SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. PITS AND/OR DRAINFIELD @ S3.00 OVERFLOW SEEPAGE PIT. DRAINFIELD EXTN..CESSPOOL.DRYWELL @ $2.00 HOUSE SEWER CONNECTING TOP.C.NO. PRIVATE DISPOSAL SYSTEM j @ 51.00 CO. IMP. NO. 3 JOB NO. WORK C N ADDITIONALUSE RL'a TRUNK PERMIT NO. ROAD PERMIT N0. , SEWER REPAIR SYSTEM HOUSE $1.00 STATE ENCROACHMENT INDU PERMIT N0. ,/ARGES 11 WAST ETAPPROVAL �L• CH ...Qy OWNEWS PERMIT S 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE Q UPJC 1 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 BE SIGNED THIS DAY OF "" 19�_' NEW HOUSE SEWER - I'll) OWNER OR �r"�_ CONNECT ADDITIONAL OWNERS AGENT `vim _BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD I HEREBY 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 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ SIGNATURE SEEP.PJT(S) C1CESSPOOLS OF PERMITTE VALIDATION---) ROBERT A. WOOD CK. M.0. GSH SUPERVISING MECHANICAL ENGINEER .' 6 8 0 5 FEES ?3 1 0 A 6.0 0 /_9� Texaaso 5.59 APPLICATION FOR PERMIT c�eoe COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL - DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION BUILDING 0 ADDRESS CASSATf D. GRIFFIN. Sup of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL I DESCRIPTION LOT NO. _S OWNER BLOCK TRACTMAIL ADDRESS N .OF BLD". SIZE OF LOT NOW ON LOT CITY TEL. NO. USE BUILDINGS DISTRICT NO, GROUP MAP PROCESSED BY nap SK PG CONTRACTOR / i, J ///I — 6 -2— ADDRESS 2ADDRESS CONNECTION DATA K 1 CITY EL.NO. — /05 STATION DEPTH STATE MANHOLE REFERENCE / �� UPPER REGISTRATION NO. O Z COUNTY No. I DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO �A' PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH ON Ar`�1 PETS AND/OR DRAPTIC TANK, ENFGIELDT OR @ $3.00 Y. CURB P.L. M.L.TO P. Willi) OVERFLOW SEEPAGE PIT, DRAINFIELD �� , �-Z/'�60 EXTN..CESSPOOL.DRYWELL @ $2.00 Y HOUSE SEWER CONNECTING TO P.C.N0. PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO, d JOB N0. WORK ECT TO HOUSE ADDIT(SEWER LDG.OR @ 51.00 TRUNK PERMIT N0. ROAD PERMIT NO. SEWER,RREPASR OR SYSTEM HOUSE $1 00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL _ WASTEAPPROVAL Q �� !M-�L-IC� �/f ✓✓l•w• CHARGES OWNER'S PERMIT $ CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE 1 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 OF 19_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL CI WI ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR PLUMBING AND SEWERS. ALTER. EPAIR,SEWERDISPOSAL OR 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGAND DISC EM LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ONNECT ABANDON HO PLUG PLUGUSE D CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ER DESCRIBED RESIDENTIAL PROP RTY SEEPFIL (SEP ❑C TANKSS CESSPOOL SIGNATURE OF PERMITTE �J ®r VALIDATION---' \ ROBERT A. WOOD CK. U.o. CASH) SUPERVISING MECHANICAL ENGINEER 680b IE-a2311 A 2 5.0 0