HomeMy Public PortalAbout9111 BROADWAY_Sewer__ .24650 INSE
CE80.6.60
TeasazD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING
LAMBIE, County q
ADDRESS
WOyHM.A. TENSEN, Bup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO Fa N CROSS ST. 5
LEGAL I
DESCRIPTION LOT NO. �^ OWNER
BLOCK - TRACT MAILt97 _ _ _ /J
ADDRESS _K4
NO,OF SLOGS.
SIZE OF LOT NOW ON LOT Z CITY ) TEL. N0.
USE OF I BUILDGSav� DISTRICT N . GROU I BK MAP PG OCESSED BY
IN ,P X�gJ
CONTRACTOR n r V V
ADDRESS49 ;2 CONNECTION DATA -
CITY TEL.N0. STATION '_.f-0 / r l DEPTH '
STATE MANHOLE REFERENCE U
REGISTRATION NO. O COUNTY `j LOWER
No: DESCRIPTION OF WORK FEE r
HOUSE
CSS SEWER CONNECTING TO @ g3.00 �t v
TYPE OF CONNECTI LENGTH FROM �J
SEPTIC TANK.SEEPAGE PIT OR - Y. CURB P.L. M.L.TO P.L. eL-
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO 'P C.NO.
PRIVATE DISPOSAL SYSTEM @ 51.00 CO.IMP. NO. JOB N0. p.
CONNECT ADDITIONAL BLDG.OR0
WORK TO HOUSE SEWER @ 51.00 TRUNK PERMIT N0. ROAD PERMIT NO. V
SEW ERROR DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT C
PERMIT NO. M
INDUSTRIAL U
WASTE APPROVAL M
CHARGES b
OWNERS PERMIT $ 2 DO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DE IBED EXISTING DWELLING APPROVALS. DATE INSPECT S SIGNATURE.
TO THE PUBLIC SE ,}
SIGNED THISDAY F �, u 1� 19 NEW HOUSE.SEWEROWNER OR
OWNERS AGENT '-'�`] - CONNECT,ADDITIONAL
/L/(
o BUILDING OR WORK
ADDRESS a �(� 0 SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I 'HEREBY ACKNOWLEDGE THAT 1 AVE READ THIS APAICATIOIQ - - - - - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYCESSPOOL [3 -0RYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY T 1 A
LY ISTE D AND/O DISCONNECT PLUG AND
LICENSED AS REQUI Y LC NTY D STATE ABANDON HOUSE SEWER
CALIFORNIA OR TH 1 AM HEY A
DESCRIBED RESIDE PROPEBACKFILL SEPTIC TANKS ❑ 1
SIGNATU da
SEEP.PIT($) ❑ CESSPOOLS
OF PER
®r DATION-1 ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
LhCo 8 5 5 6 JUPJ 1 4 1 0 0 Jr.L