HomeMy Public PortalAbout9064 BROADWAY_Sewer__ °
9 a a-683 9-55
APPLICATION FOR PERMIT _
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer --
County of Los Angeles emLDNw c
ADDRESS 7764.
- WM.J. FOX, COUNTY ENGINEER E. Broadway
CASSATT D. GRIFFIN, SUPT OF BwLDINe LOCALITY Temple City
FOR APPLICANT TO FILL IN c oRSR sT. Ro s em a ad Blvd.
LEGALq W. H. Johnson
DESCRIPTION LOT NO.eC OWNER.
BLOCK TRACT NAIL
ADDRESS Sa�H c
SIZE OF LOT NOWOONBLOTS CITY TEL. N0. AT--61 /n
5 O
USE OF
BUILDINGS DISTRICT NO. GROUP j�C MAP.'/J
CONTRACTOR John N. Buchanan
ADDRESS 13244 9. Ramona Blvd. , CONNECTION DATA
C1T1Baldwin. Parti TEL. NO.ED-7,6;213 STATION DEPTH
c [ry��+ STATE MANHOLE R.FERENCE UPPER
REGISTRATION NO. 121537 LJ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE TYPE OFJ�/iNECTION LENGTH FROM
1 PUBLIC SEWEREWER CONNECTING TO Q S 3.50 3150 Y. CARB7' P L M L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR P. C. NO.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. JOB NO.
ALTER OR REPAIR EXISTING /
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
AN D/ORNDISPOSAL SBANDOSTEMN SEWER 1.00 1. 00 STATE ENCROACHMENT
PERMIT NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Z.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'SS 1 00
AUTHORIZATION TOTAL FEE 5 561 REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER t '
SIGNED THIS_—DAY OF 19 NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL J_ 1
OBUILDING OR WORK
WNERS AGENT /y>— �L� �
SEPTIC TANK, P. PIT(S)
ADDRESS AND/OR DRAINFIEFIELD
1 HEREBY 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 SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND,STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ARAN DON HOUSESEWER
DESCRIBED RESIDENT I PROPERTY. BACKFILL SEPTIC TANKS[�'
SEEP. PIT(1) ❑ CESSPOOLS❑
�j
OF PERMITTEE
SIGNATURE 6^`T
WIL`.LIAM J. O , COUNTY ENGINEER VALIDATION R. A.WOOD, CHIEF PLBG. INSPECTOR
Y 50T
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0-66 3 APPLICATION FOR PERMIT
76A642D
]6A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION El
LDING L�
JOHN A. LAMBIE, County Engineer ADORE
`�Q 6 I� OCL 4V 6L
WILLIAM A. JENSEN. Sup'1 of Building
ALITY _eM�/[• ��
" ST 1
FOR APPLICANT TO FILL IN CROSI
LEGAL
DESCRIPTION LOT NO. OWNER 13, j
MAIL
BLOCK TRACT ADDRESS
NO, OF LOGS.
S12E OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROLES O BY
(�) +// BN PG
CONTRACTOR Q n /Y /.^'1..n+/' z 1 X //
ADDREsrss 1L1 L C /LJ /// CONNECTION DATA
CITY TEL. NO. 4 � ' 0 STATION DEPTH
Q Q-STATE M ANHOLE R EFERENCE UPPER
REGISTRATION NO. / 6 ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE I TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO , CURB P.^. V M.L.TO P.L.
PUBLIC SEWER 55Go P�INOj/�J�1- a
SEPTIC TANK,SEEPAGE PIT OR MPNO - ^ L O
PITS AND/OR GRAINFIELD ® 5
I0
,00 -CO,. . . �_ v
HOUSE SEWER CONNECTING TO TRUNK PEO NO. L Rp O PEBLIIT7`1714
PRIVATE DISPOSAL SYSTEM 53.00 �L..
CONNECT ADDITIONAL BLDG.ORAFFIDAVIT I WAIVER I rkrEMENT RECORD.INSTR, NO. DATE O
WORK TO HOUSE SEWER ® 33.00 F
OVERFLOW SEEPAGE PIT.DRAINFIELO V
EXTN.,C ESSPOOL.DRYWELL.MA NH OLE 9 $5.00 W
ALTER,REPAIR OR ABANDON HOUSE NWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM ® S3.00 1 STATE ENCROACHMENT z
/•` ERMIT NO.
L
INDUSTRIAL
.I A // _
,
OWNERS CHARGES
PERMIT 5 2 00
AUTHORIZATION I TOTAL FEE y CONNECTION C RGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE I NSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
DRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(S)
qN0/OR DRpINFIELD
STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
VHT
WITH ALL COUNTY ORDINANCES
S wND STATE LAWS REGULATING
PLV MBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED PND/OR ALTER, REPAIR,SEWER OR
LICENSED p5 REOUIRE0 BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG ANO
RESIDE IN, THE ABO" D C IBEG ESIDE TIAL PROPER ABANDON HOUSE SEW ER
SIGNATURE
OF PERMITTEE_ -
BACKFILL SEPTIC TANK$ ❑ m/�
_ SEEP.PIT I51 ❑ CESSPOOL KI `/
_c VALIDATION ROBERT A
M.0. CASH SUPERVISING MECHANNICALICAL ENGINEER
3 8 5 9:� i-Lkl 1. 4 1 O D 5.00—