HomeMy Public PortalAbout9170 BROADWAY_Sewer__ 76AEAPPLI-C•ATION' FOR PERMIT
5 e
E.-86663 12.1E
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depaxtment of County Engineer
County of LOB Angeles ADDREISSGW 713
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. SUPT GF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST TNO.tl�-t
CROSS ST.LEGALDESCRIPTION LOT NO. � !CC BLOCK TRACT 1 MAILADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LO CITY Lr
USE OF
BUILDINGS DISTRICT NO. GRDUP MAP
CONTRACTOR BK PG
T}<'�
ADDRESS /S CONNECTION DATA
D N� Zvi
CITY TEL. NO. • y STATION I } 2,e DEPTH C1- 0
[I STATEREGISTRATION NO. ❑ COUNTY , �t� S �NACUPOEEREFERENCE
TYPE OF G9,[INECTION EDO LENGTH FROM o
NO. 'DESCRIPTION OF WORK FEE .Yr (LURB7 'Pel. M.L.TO P.L. �-
HOUSE SEWER CONNECTING TO ...n
PUBLIC SEWER Q $ 3.50 �k pv
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. I JOB. N0.
WORK TO HOUSE SEWER 1.00 �.Lj� G+�Z_
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 STATE ENCROACHMENT
PERMIT NO.
SEPTIC TANK. SEEPAGE PIT OR f
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL-
SPECIAL CONDITIONS ONLY 2.00CHARGES
PERMITCONNECTtOCHARGE FEE
OWNER'S 5 1 00 ` ___1�
AUTHORIZATION TOTAL FEE !&0 REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS "4L-DAY �:.rA NEW HOUSE 5EW ER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENTX "� ..[e az 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 STATE LAWS REGULATING ALTER. REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OF
LICENSED AS RECUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG ANDABANDON HOUSE SEWER I
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED P.ESIDENTIAL P PE BACKFILL SEPTIC TANKS❑ �r1*
SEEP. PIT(S) El CESSPOOLS
SIGNATURE •�
OF PERMITTEE - - -
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY 'A(oa 437-' MAR 10 4 5.50 m-By
_
DEPUTY DEPUTY `
BY BY
•® DEPUTY DEPUTY