HomeMy Public PortalAbout9105 BROADWAY_Sewer__ CE8083-62 APPLICATION FOR PERMIT '
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION au ILDING
TORN A. LAMBIE, County EDgine er ADOREss
WILLIAM A. JENSEN. Supt of Building �.
LOCALITY
NEAREST -
I\ FOR /PP I-ANT. T FII.L IN / `ROSS BT
Lam- EGALV L {� 5-11-0
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DESCRIPTIONONLOT O. Y OWNER
X MAIL
BLOCK y TRACT j� .(.�J ADDRESS r
NO, OF BLDGS.
SIZE OF LOT NOW N LOT CITY C TEL. NO.
UBE OF DISTRICT GROUP MAP
PG
CONTRACTOR PROCESSED BY
BUILDINGS
{/� BK
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ADDRESS CONNECTION DATA
CITY
STATION - DEPTH
O.
❑ STATE MANHOLE REFERENCE ,y / UPPER
REGISTRATION 1 / _ C3 COUNTY
NO. DE$C IP --iNO/{FJ K FEE TYPE OFC CTION LENGTH FROM }
/ HOUSE SEWER CONNECTING TO Y, CUR P.L. M.L.TO P.L. g
PUBLIC BEWER @ 35.00 V
SEPTIC 'GRAINFIELD
PIT OR P.C.NO. U
PITS AND/OR GRAINFIELD @ 310,00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM 33.00
CONNECT ADDITIONAL BLDG.OR I AFFIDAVIT MV[p 51p[ RECORD.INSTR.NO. 15ATE
WORK TO HOUSE SEWER 53.00 LLLLLLIII
OVERFLOW SEEPAGE PIT.DRAINFIELDI y
EXTN..CESSPOOL.DRYWELL.MAN HOLE 55.00 y
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING L_
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $1 21 o0 CHARGES
AUTHORIZATION TOTAL FEE 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 INSP EC OR SIGNATURE
SIGNED THIS DAY OF 45t19
l
OWNEROR NEW HOUSE SEWER (AT I/I.��
OW NERS AGENT A
CONNECT ADDITIONAL
ADDRESS_ Cpl BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ S APP AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP Y
WITHALL COUNTY ORDINANCES AND STATE LAWS REG ULATI G
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT IAM 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 OWN OF, AND IN NO TO DISCONNECT PLUG AND /
RESIDE IN. THE ABOV CRIBED RE TIAL PRO7flT ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ ❑/Im �(�
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT WOOD
�
CK. M.D. usH SUPERVISING MECHANICAL ENGINEER
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