HomeMy Public PortalAbout9126 BROADWAY_Sewer__ 2"°
76A 6g2D APPLICATION FOR PERMIT
T6A
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONJ�IT�
DING
JOHN A. LAMBIE. COUNTY ENGINEER An
�. 6 I/ I,QrL><i q'L` Y
COLEMAN W. JENKINS. SUPT. OF BUILDINALITY
FOR PP LICA NT TO FILL IN REST
(PRINT OR TYPE ONLY) 55 SL
LEGAL
DESCRIPTION LOT NO. ER
BLOCK Tfl<CT RESS / �/NO. OF BLOGB. ? (e �A/ TEL. NO. �512E OF lOT NOW ON LOT �C'
USE OF
BUILDINGS DISTRICT NO. GROUP CLASS MAP PROCESSED BY
/' B N p�S/
CONTRACTOR 2 T �'h�q/� ( O. � � f� � � / /'1
ADDRESS t/t./ i.- //q11 U CONNECTION DATA �l�
(/ / STATION DEPTH
CITY � � TEL. NO. 7 I
STATE L p LIC /' j MANHOLE REFERENCE UPPER
LICENSE NO.. 26 CLASS ` LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONN E ON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® 55.00
SEPTIC LANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFfELD SU0.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD MIT NO. T
PRIVATE DISPOSAL SYSTEM 53.00 p_
CONNECT ADDITIONAL BLDG,ORAFFIDAVIT AIY 51YXX RECORD.INSTR. DATE O
WORK TO H OUSE SEWER 53.00 v
OVERFLOW SEEPAGE PIT.GRAINFIELD
E%TN..CESSPOOL.DRYWELL.MANHOLE @ 55.00
' P!®fMREPAIR�HOUSE /�T�J�/ HWY.OR ST.WIDENING O
'Yip.�L
SEWERSYSTEM @ 53.00 •" STATE ENCROACHMENT 1-
PERMIT
PERMIT NO. W
INDUSTRIAL d
N
WASTE APPROVAL z
CHARGES
OWNER'S PEFimrr s 00
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 INSPECTORS SIGNATURE
SIGNED THIS DAY OF1�Z
OWNER / "A "��� NEW MOUSE SEWER
A � Cll�ii
OWNERS AGENT ALJ. /' -
CONNECT ADDITIONAL
ADDRESS '� Y BUILDING OR WORK
SEPTIC TANK.SEEP.PITI51
1 HEREBY THAT
THE DGEABO THAT HAVE READ THIE,gTO CO TION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IE CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCEB AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DftYwELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAI EWER OR
LICENSED AS REOUIRE0 BY LOS ANGLES COUNTY ANO STATE OF SEWAG DEAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABO' DESCHI RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE GY A�.&ABACKi1LL SEPTIC TANKS ❑
OF PERMRTEE [SII" SEEP.PITI51 ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
.0[p 6.'3 A 6:N VJAY 31 1 0 D 6.00-
o