HomeMy Public PortalAbout9222 BROADWAY_Sewer__ 80AG48t0-63 P
76APLICATION FOR PERMIT
TE
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST + �
FOR APPLICANT TO L V,4
LEGAL /I
DESCRIPTION LOT NO. / OWNER .�� (7 G/I/
MAIL
BLOCK TRTCT AOGRESS
NO. OF BL G5.
SIZE OF LO NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG y/
CONTRACTOR- /�Gq
ADDRESS RJ. (/ CONNVVVECTION DATA
STATION DEPTH
CITY EL.
STATE MANHOLE REFERENCE 81
REGISTRATION RI' COUNTY LOWER
NO DESCRIPTION F WORK EE TYPE OF CONNECTION LENGTH FROM C
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER $5.00 �—
SEPTIC TANK.SEEPAGE PIT OR - P C NO /L O
PIT.ANO/OR DRAINFIELD Q $10.00 CO.I.P. NO. JOS NO. Cl
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTE M 53.00 w
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I IMVel1 1AS14INT RECORD.IN.TR.NO. DATE O
WORK TO HOUSE SEWER 83.00
OVERFLOW SEEPAGE PIT,DRA(NFIELD U
EXTN_CESSPOOL.DRYWELL.MA NHO LE® 85.00 W
CL
ALTER,OIRORA ON MOUSE HWY.OR ST.WIDENING N
SEWER OftR DISPOSAL SYSTEM ® 53.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S z 00 CHARGES
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 5EWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ I f
OWNER OR NEW HOUSE SEWER
OW NERSAGENT
A CONNECT ADDITIONAL r
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PITIS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
W ITN ALL COUNTY ORDINANCES AND STATE LBWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY TH 4M PROPERLY REGISTERED ANDIOR ALTER.BE AIR.SEWER OR
LICENSED AS REOVI BY . ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T 1 AM T E LEGAL NER OF. AN INTEND TO DISCONNECT PLUG AND
BESIDE IN, TME OVE DE RIBED R ENTI PRO ERTY. ABANDON HOVE SEWER
BIG NATURE BACKFILL SEPTIC TANKS ❑
OF PERMITT SEEP,P'T(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK. M.O, cases SUPERVISING MECHANICAL ENGINEER
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