HomeMy Public PortalAbout9132 BROADWAY_Sewer__ ••�76A6420 APPLIClAT1011I,�FOR' PERMIT 1
5 G E.663 12.54
'DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
• Department of County Engineer
County of Lob Aagolee 601 LDING
WM. J. FOX, COUNTY ENGINEER ADDRESS t
CASSATTD. GRIFFIN, SUPT OF BUILDING -
` LOCALITY T•
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL yy '02
DESCRIPTION q. LOT NO. /.� SJ �O./AOf �O OWNER)I
BLOCK R TRACK �a, R , D1 L Iia
N0.OF BLDGS. J
SIZE OF LOT NOW ON LOT: CITY TEL. NO
BUELDINGS}� »/[�/l/�t/���C- ' DISTRICT.NO. G� MAP
CONTRACTOR BK
PG
ADDRESSLo
/'� !�-^! �• CONNECTION DATA
CITY A- TEL. NO.J_Q GC14 op� STATION �,`��O - 4' DEPTH
❑ STATE 8/]L/ ,1A1 MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY ``'��l�' tV/�V( 6ABBR•'- LOWER
TYPE OA TCEALECTION LENGTH P.L.
No. DESCRIPTION OF WORK FEE Y. /CURB J P.L. M.L.TO P,L. J
HOUSE SEWER CONNECTING TO
PUBLIC SEWER III S 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG- OR CO. IMP. N0,oL 7 JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING -- -cy_O v
-SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0. 2J�J
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL-SYSTEM 1.00 STATE ENCROACHMENT
PERMIT N0.
SEPTIC TANK, SEEPAGE PIT OR ---
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S s oa
AUTHORIZATION TOTAL FEE ¢ d REIMBURSEMENT FEE
CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBEDCTED WITH-THE. EXISTING A DWELLING APPROVALS DATE INSPECTOR'SSIGNATURE
TO THE PUBLIC SEWER
��L _ NEW HOUSE SEWER A
SIGNED THI DAY OF �!///ter p 1�9s� Z > >>�A�10 L, r�—
OWNER, ORE �iL� 7L CONNECT-ADDITIONALOWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS - - - AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I 'HAVE READ THIS APPLICATION .CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE-IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATELAWS REGULATING DETER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE _
WILLIAM J. FOX. COUNTY ENGINEER - VALIDATION
-'BT = :r: 406'3-7n FEB 17 4 4.50 m
-T .DEPUTY DEPUTY
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�® DEPUTY EPUTY