HomeMy Public PortalAbout9018 BROADWAY_Sewer__ APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BUILDING - O/ T7R0/'�� �l/
JOHN A. LAMBIE, County Engineer ADDRESS /J
WILLIAM A. JENSEN. SuP t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS sT. /yf r �♦�/��� /��
LEGAL
DESCRIPTION LOT NO. .� OWNER
r/ MAIL
BLOCK TRACT ADDRESS
. 6o r��o NO. OF BLDGS. �j
SIZE OF LOT /' NOW ON LOT \ CITY TEL. NO.
USE OF D15TRICT NO. GROUP MAP PROCESSED BY
BUILDINGS r(c /'♦� �J (` /� P.
CONTRACTOR ].y�1{, /, SG' TZI
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ADDRESS l 7.:?0 /—� / 37 r-4 •p �,VV CONNECTION DATA'/ l�T�
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�VL NH. TEL. NO. r��IOeO' STATION DEPTH y
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REGISTRATION rv0. _ TE MANHOLE REFERENCE
.J �C COUNTv
NO. DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION LENGTH FRO d
OUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. O
PUBLIC SEWER ® 53.00 P.C.NO. V
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS ANO/OR DRAINFIELD @ $'000CO.IMP.NO. �
HOUSE SEWER CONNECTING TO THUNK RMJJ j! O ij! �T NO. O
PRIVATE DISPOSAL SYSTEM 13.00 L L ♦ F
CONNECT ADO ITIONAL BLDG.OR AFFIDAVIT uv 1AII.IIIT RECORD,INSTR.NO, OATS W
WORK TO HOUSE SEWER 53.00 OO a
OVERFLOW SEEPAGE PIT.DRAINFIELD IA
EXTN_CE5SPOOL.ORYWELL,MAN HOLE 054,00 HWY.OR ST.WIDENING Z
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC 5EWER. DATE INSPECTOR'5 SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORKSEPTICOC o
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
T(B)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR OflAINFIELO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OW NE F, AND INTEND TO DISCONNECT PLUG AND
RE51DE IN, THE ABOVE D CRIBE REBIDBN A PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITTEE_ BEEP,PIT(S) ❑ CESSPOOLS ❑
�}(ALIDATION ROBERT WOOD
(` cKK/. J M.O. I CASH SUPERVISING MECHANICAL ENGINEER
�C lt,';o 5 2 7 6 ;.IIY 2'7 1 ,7 D 5
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