HomeMy Public PortalAbout9083 BROADWAY_Sewer__ a
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TeABa2APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. . DENSE, .CountyS.p't Engineer ADDRESS O 'r� j,��/� }� r.
ci
WILLIAM A. ]ENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST' _ _r �_ N C
LEGAL P�
DESCRIPTION LOT NO. n/ OWNER C AA
-v--/—/ MALI O4 —,
/ �G
BLOCK TRACT ADDRESS LXr •-
SIZE OF LOT / �6 NOWOONB LDTS oI CITYL AA N TEL. NO. —6
674
BUELOINGS QS I_dQ I` DISTRICT`�NO. GROUP MAP3K RD PROCESSED BY
CONTRACTOR [ SA �U T L 7 COLO VI
C()
ADDRESS a r.0 CONNECTION DATA
cITT 1 /1/LLTELL. NO. /� � STATION7 "/ �. DEPTH `/ ��
STATE MANHOLE REFERENCE !S� c� / UPPER
REGISTRATION NO. B COUNTY //_ If G .J
NO. DESCRIPTION OF WORK FEE TYPE OF .CTION LENGTH FROM 33 O
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® 55.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR i�q ��
PITS AND/OR GRAINFIELD @ 5I0.00
P. NO,
J JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 9Z.31`y
PRIVATEDISPOSAL EWERCONNECTEM E3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT [ EENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 AI[/[
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.ORYWELL,MA NH OLE(11? S5.00 S�
X ALTER.REPAIR OR ABANDON HOUSE '$
Pa HWY.OR ST.WIDENING
SEz
SEWERR (10OR DISPOSAL SYSTEM 83.003 ✓ STATE ENCROACHMENT
rSGON PH `ff ZAS PCRM IT NO.
`�0/ INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s 200 CHARGES
AUTHORIZATION I TOTAL FEE =0 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
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S S I.—
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(S)
AND/OR GRAINFIELD
AN STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING C1PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREST CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSEO AS REQUIRED BY LOS. ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TN AT 1 tHE LEGAL OWNER OF. INTEND TO DISCONNECT PLUG AND q I
RESIDE IN, THE ABOVE SCRIBE IDF�N AL P Y. yo�7
C ABANDON HOUSE SEWER (. v
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_ 5EEP.PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
�r�l 0 3 1 9 0 G APR M o D 5.0 J- s
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2 APPLICATION FOR PERMIT
5aiI�SS -
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
-Depwirnent of County Engineer -' -1County of.Los Angeles BUILDING �A(j 1 ��
JOHN A. LAMBIE, COUNTY ENGINEERADDRESS / /(1 /'�
® CASSATT D GRIFFIN. SUPT OF BUILDING LOCALITY A'L p i�1 r 1
FOR APPLICANT,TO FILL IN C"RSs sT. / T
LEGAL �y OWNER
DESCRIPTION LOT NO., , G/
MAIL
BLOCK TRACT r ADDRESS n T1
SIZE OF LOT�(/; Ffr9)(�/N�7$f-ON L S / CITY `V " TEL. NO. -
USE OF 5i- P -
BUILDINGS DISTRICT NO. GROUP h MAP
BK PG
CONTRACTOR 1 317 GOL EG ROVE AVE. --L/�
ADDRESSCONNECTION DATA
MONTEBELI PA -5(LB
- $70.7ION DEPTH
CITY ^^c��TEL. N0.� MANHOLE REFERENCE �UPPER.
_ TRD I ❑ 'STATE
REGISTRATION NO. ❑ COUNTY
NO, DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF N ION LENGTH FROM
_ PUBLIC SEWER @ $ 3.50 J�' Y' URB P.L. M L TO P L.
SEPTIC TANK,SEEPAGE PIT OR ,
_ PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELDP. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. N0. JOB NO. qq,,
HOUSE SEWER CONNECTING TO (.@ $1.00v�
PRIVATE DISPOSAL SYSTEM Op TRUNK PERMIT NO. ROAD PERMIT N0. !J
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL'
CHARGES
�� �•r"-^ ' /' 4 CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION ITOTAL FEE L REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED-�C7DN- APPROVALS DATE INSPECTORd51tGNAT'UBE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING.
1'0 THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THISOgYOF /•• 19 ,17
CONNECT ADDITIONAL
OWNER OR. ��/�� BUILDING OR WORK
OWNERS AGENT
SEPTIC TANK,SEEP,PIT(5)
ADDRESS z AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 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
IHEREBY 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 THA I AM T LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENNTPROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE ,J �j SEEP. PIT(S) ❑.CESSPOOLS
OF PERMITTEE \• L '/
JOHN A. LAMBIE, COUNTtF/hGIqiEp4VALIDATION ROBERT A. WOOD. CHIEF FLOG. INSPECTOR
N.O. LASH '
LCp2463V! MR 31 4A 4.50