HomeMy Public PortalAbout9040 BROADWAY_Sewer__ &SO 6-} 6'9 /IISUlTfINfl—711F
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7A°420 APPLICATION FOR PERMIT
ceeoe-e-ea COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING co
JOHN A. LAMBIE, C000ty Eogineee ADDRESS G
CASSATT D. GRrPM. Sup'1 of BuBdfvg LOCALITY aU tiI
NEAREST
FOR APPLICANT TO FILL IN I CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
IlaADDRESS
NO.OF BLDGS.
' SIZE OF LOT NOW ON LOT
CITY TEL.N0.
USE OF
BUILDINGS DISTRICT N0. GROUP MAP PROCESSED BY
r j BK -PG
CONTRACTOR �AvY i' _ 5 ,
v
ADDRESS I CONNECTION DATA
CITY TEL. NO. . `j nj �/ STATION ��3/ DEPTH
r / tSTATE .
REGISTRATION NO. ''S 7 S �+ •'COUNTY MANHOLE REFERENCE
NO. DESCRIPTION OF'WORK FEE - LOWER '
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK. SEEPAGE PIT OR TYPE OF ION LENGTH FROM /
PITS AND/OR DRAINFIELD @ $3.00 Y. UR P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MA NHOLE @ $2.00 '
HOUSE SEWER CONNECTING TO P.C. N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 Co.IMP.N0. JOR N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. a`
WORK TO HOUSE SEWER @ $1.00
SEWER'OR PAIR DISPOSAL SYSTEM HOUSE 0 $1.00 OR ABANDON STATE ENCROACHMENT -
PERMIT N0.
INDUSTRIAL
_ WASTE APPROVA
_
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CH AGE FEE
i AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPAOVALS� DATE , INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 1S_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWN ERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT($)
ADDRESS _AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
ANO 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 ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES CQTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA-OR THAT I AM THE LEGAL OWN R OF THE ABOVE
DESCRIBED RESIDENTIAL-PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE ��!/G/� ..y_/V� /, SEEP. PIT SI ❑ CESSPOOLS r Y LGfPf/ �Y
` OF PERMITTEE— C =,,f �•�_��'/ 7<-,` J '
®r ` VALIDATION ROBERTA.WOOD
CK. B.o. CASe SUPERVISING MECHANICAL ENGINEER
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