HomeMy Public PortalAbout9023 BROADWAY_Sewer__ 98AB40D
5 @ C-6.3 1199 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS ��/ 3 &&
YJ CASSATT D. GRIFFIN. SUPT OF SUiLOING
LOCALITY TE�/J`�C I!Z �y
FOORRyAPP,LIgANT TO IyI caoss sT /moi i-
LEGAL VY •rsT. /
DESCRIPTION LOT NO. �9 OWNER
MAIL
BLOCK TRACT Sli.777) y P,'e,w ADDRESS
Y.
N45.OF SLOGS. CITY �. C� E 4;Q 114
SIZE OF LOT NOW ON LOT L. NO.
USE OF A-1 / �j-i YDISTRICT NO. GROUP MAP
BUILDINGS in C BK PG
CONTRACTOR 7J L U
CONNECTION DATA ff
ADDRESS
STATION DEPTH
CITY TEL. NO. MANHOLE REFERENCE UPPER
❑ STATE LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L.TO P.L.
SEPTIC SANK, EPIT OR
PITS ANO/OR GRAINFIELD @i $3.00 _ ]
OVERFLOW SEEPAGE PIT. GRAINFIELD 4
CO. IMP. N0. JOB NO.
_ E%TN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
_ WORK TO HOUSE SEWER (rl' $ I.00 PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ S 1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00 '
AUTHORIZATION TOTAL FEE 00 REIMBURSEMENT FEE HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
APPROVALS BATE I INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS PND/OR DRAINFIELD
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND $EWER$. 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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
/� n SEEP.PIT(S) ❑ CESSPOOLS❑
SIGNATURE, a _ // p A? �_ //�
OF PERMITTEE-I"71f�C1' ififi/AI
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION y� ROBERT A. WOOD, CHIEFPLBG. INSPECTOR
f 9 6 6.4,R MG 28 4 2.0 0