HomeMy Public PortalAbout9214 BROADWAY_Sewer__ 76AS42D APPLICATION- FOR PERMIT 1
SII E-GGS 11.59
DIVISION OF BUILDING AND SAFETY. SEWER—SEWAGE DISPOSAL
• Deportment of County Engineer _
County of Los Angeles BUILDING /p /
-JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D.GRIFFIN. SUPT OF BUaowc
FOR APPLICANT TO FILL IN NEAREST
T. jfl/y
��i.�•
LEGALOWNER
DESCRIPTION LOT N0.
1,. MAIL
BLOCK TRACT `/v _( ADDRESS
N0.OF BLDGS. �j CITY TEL. NO.
SIZE OF LOT NOW ON LOT </
USE OF c^ �' - DISTRICT NO. GROUP MAP
BUILDINGS S'i�i j��"'� .yam BK PG
CONTRACTOR .ZU� 1 Ze-
`l5�11/1//��„ .i, CONNE-JCTION DATA
ADDRESS
STATION DEPTH
CITY "/fin i� TEL. N0.
Q}[I MANHOLE REFER NC _ _ UPPER
-STATE ( /may /J 5- / LOWER
REGISTRATION NO. �� COUNTYy------C'�N!/ �
-NO. DESCRIPTION.OF WORK FEE _
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION NGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB \ P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL.MAN HOLE @ $2.00 CO. IMP. NO. x JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. ,
CONNECT ADDITIONAL BLDG.ORSTATE ENCROACHMEN - -
WORK TO HOUSE SEWER. @ S 1.00 j 0
PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM _@ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s o0
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE.
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
_ TO THE PUBLIC SEWER. - NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL.
OWNER OR - BUILDING OR WORK
OWNERS AGENT _ SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD - -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL Q DRYWELL L)ANO STAG.,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
1HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
DISCONNECT ABANDON HO PLUG PLUGAND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
USE SEWER
DESCRIBED RESIDENT] ///FO PERTY. ///� / . BACKFILL SEPTIC TANKS 173 -
SIGNATURE �/ / �!� /n/, SEEP.PIT(5) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD.CHIEF PLSG. INSPECTOR
IX.
LAC,0 5 1 5 1 m SEP 2 4 1 A . 2.0 0 P.