HomeMy Public PortalAbout9027 BROADWAY_Sewer__ CE9G610-63
76A662D APPLICATION FOR PERM
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS 0;z
WILLIAM A. IENSEN, Sup't o1 Building �{
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ORo55 sT. a G d
LEGAL �A ` DA rA /` OWNER
DESCRIPTION LOT NO. y I_ rV I- /v
MAIL
BLOCK TRACT ADDRESS 90.2- 47
NO. OF BLDGS. �� / Q
SIZE OF LOT NOW ON LOT CITT / y-- t TEL. NO, (e
USE OF D15THICT NO. GROUP MAP /PROCESSED B
BUILDINGS ey
PG / )
CONTRACTOR n W!✓Q J r•_/•, l/ ,�/'/'/
ADDRESS D 2. �j` �p CONNECTION DATA
CIT �z fJ TEL, NO. �Y `p B -7 STATION DEPT
-/_•` STAMANHOLE REFERENCE V)E UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB .L. M.L.TO P.L. }
PUBLIC SEWER $5.00 P.C. O, d
SEPTIC TANK.SEEPAGE PIT on CO.IMP. NO. JOB NO, O
PITS AND/OR GRAINFIELD 5I0.00 U
HO U SE SEWER CONNECTING TO TRUNK PERM IT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wuv RU"11 flECOftD.INSTR.NO. DATE O
WOR K TO HOUSE SEWEfl @ 43.00 QV �rJ
OV
G
-
F
L
OW
SEEPAGE PIT,ORAINFI[L° W
%TN..CESSPOOL.ORYWELL,M ANHOLE� ES.00 HWy.OR 6T.
ALTER,REPAIR OR ABANDON HOUSE , h
_SEWER OR DISPOSAL SYSTEM E3.00 STATE ENCRO CHMI.NT
{� s E ( SYSTEM
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z 00
AUTHORIZATION TOTAL FEE 3 Q CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS _
TO THE PUBLIC SEWER. DATE INSPECTOR'5 SIGNATURE
SIGNED THIS �DA OF L17--e- 19Lr4
OWNER OR ` 1/✓1_ � A _��L NEW HOUSE SEWER
OWNERS AGENT F _ I",//AA✓✓VV LLLL CONNECT ADDITIONAL
BUILDING OR WORK
ADOflEss_ SEPTIC TANK.SEE P.PIT(S)
I HEREBY ACKNOWLE G THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE A OVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ r
I HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR ALTE R.REPAIR,SEWER OR 1
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF3EWAOHDISP.OSAL.Sy$F6U4 /1" S -. ?7iY
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND I ( J 7
RESIDE IN. THE ABOVE DESCRIB D RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP,PIT I51 ❑ CESSPOOLS
ALIDATION ROBERT A. WOOD
CASH SUPERVISING MECHANICAL ENGINEER
Ltti� 6 4 1 8 DEC 3 1 0 D 5.0 0-