HomeMy Public PortalAbout9102 BROADWAY_Sewer__ CEOOO 5-65 APPLICATION FOR PERMIT F
TGA 6420
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eclLDlrvc O
JOHN A I.AMBIE, County Engineer ADO RE55 J--
COLENIAN R'. JESKINS,Supt. of Building y�
LOCALITY /� J✓1p t��
NEAREvT K
FOR APPLICANT TO FELL IN GRD55 ST.
LEGAL
DESCRIPTION LOT NO. OWNER
rte'
BLOCK ® TRACT / NO I r AMADDRESS ` / l-
-ILOO SLOGS.
SIZE OF LOT NOW ON LOT CITY L. NO.
USE OF DISTRICT NO. ROUP MAP PROCESSED BY
USE OINGS
BK PG
CONTRACTOR ) � .4'�� G f
ADDRESSqv 6 ) L_?/ V JJ'�� CONINE`C71ON DATA
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(� �f y STATION DEPTH
CITY y`/ I-ZTEL. NO. J `
LIC 5f. r- LICENSE r r• UPP
NO. 1 CLA 55 MANHOLE REFERENCE U �
NO. GESC IPTION OF WORK FEE TYPE OFC.MLENGTH
LENGTH FROM
HOUSE SEWER CONNECTING TO '�� Y. UR F.L. M.L.TO P.L. b
PUO LIC SEWER e $ 5,00
TIC_7_AN71E G IT OR ^ P.C.NO. �•
PITS AND/OR DRAINFIELD F $10.00 CO.IMP. NO. J JOB NO, d
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT uv Azu[ RECORD, INSTR,NO, DATE �•
WORK TO HOUSE SEWER € 4 3.00 O
PBA! N HOUSE F
SEWER DR DISPOSAL SYSTEM C �I
O�LH [Fpp OE- 0 H W Y.OR ST.W I DEN I NG WWa
CESSPOOL, MANYOLE 0 $ 5.00 STATE ENCROACHMENT y
PERCOLATION TEST @ j 5.00 PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s z o0
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 'G
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIM8URSEMENT FEE 41/0'
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — N
TO THE PUBLIC SEWER, APPROVALS GATE HrSPECZ.'S SIGNA'�IRE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU ME TNG AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, kNQ INTEND TO DISCONNECT PLUG AND
RESIDE IN. TH VE DESC
�RJILED RESIDE NTI PROpERT .
ABANDON HOUSESEWER ^
SIGNATURE ❑
OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP,PITIS) ❑ CESSPOOLS 2� `
IDATION
CK.
M.0. CASH
Ao 2 0 5 8 DEC 7 '_ 0 D 7.0 O