HomeMy Public PortalAbout9082 BROADWAY_Sewer__ 76A642o APPLICATION FOR .PERMIT {�
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION au aDlNc
JOHN A. LAMBIE, County Engin.°r ADDRESS
WILLIAM A. JENSEN. SuP't of Building
LOCALITY L
NEAREST v 1
FOR APPLICANT TO FILL IN CROS$ ST.
LEGAL I p T
DESCRIPTION LOT NO. OWNER �'+� - \ p— jj 1
MAIL
BLOCK TRACT ` Z 1
p.,./ AGGRESSNF ( �(T (�''I
512E OF LOT
OW
}l,//K I ��-� NOON LOT y CITYTF,_ U � U\ TEL. NO. �^G_J I
USE OF TO
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OUILOINGSC�OMA�C WG.1_l..\ "Iza DISTRICT NO.1 GROUPI MAP PROCESSED BY
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CONTRACTOR O`f� 1 D
ADDRESS :CONNECTION DATA
CITY TEL. NO. STATION DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY7 01 LOWER
NO. DESCRIPTION OF WORK FEE TYPE OFC N£GT N LENGTH FROM
HOU5E SEWER CONNECTING TO ,�p� Y, CUR P.L. M.L.TO P.L.
PUBLIC SEWER @ s3.00 v(�
SEPTIC TANK,SEEPAGE PIT OR P.C.N0.
PITS AND/OR GRAINFIELD @ EIO.00 CO.I.I.NO. 30B NO, u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I *AI-I [ASIn[XT 7ORD.INBTR.NO. DATE
WORK TOHOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
E XTN_CESSPOOL.DRYWELL.MANN OLE 111 $5.00 HWY.OR ST.WIDENING
ALTER.HER IN OR ABANDON HOUSE
SEWER OR OISPOSgL SYSTEM @ S3.O0 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z o0
AUTHORIZATION TOTAL FEE W) CONNECTION CHARGE FEE
1HAVE AT THIS DATE a CONTRACT WITH THE HEgEIN NAMED CON- REIMBURSEMENT FEE , ^
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE I NSPECTOR'SSIGNTUE;
SIGNED THISOgj OF 19OWNER OF,
_ � AR�,
OWNERS AGENT �/ ^� NEW HOUSE SEWER '
CONNECT ADDITIONAL
ADDRESS I'
BV ILDING OR WORK
SEPTIC TgNK,SEEP.
I HEREBY ACKNOWLEDGE THAT I HAVE REND THIS APPLICATION PIT(S)
AND/OR GRAINFIELD
WITH STATE THAT THE ABOVE IS CORRECT AND COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS LBWS REGULATING El
IIT
AND SEWERS. CESSPOOL LlORYW ELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A OV DESCRIBEW REB NTIgL PROPERTY. ABA NDONHOUSE SEWER
SIGNATURE �* BACKFILL SEPTIC TANKS Cl
OF PERMITTEE BEEP,PIT ISI [1 CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
(
CK.J M.0. CASH SUPERVISING MECHANICAL ENGINEER
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