HomeMy Public PortalAbout9232 BROADWAY_Sewer__ ` A642D -83 APPLICATION FOR P MIT
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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. Sup'I of Building T
LOCALITY /
NE4REST
FOR APPLICANT TO FILL IN ROSR 5 [� TG ✓
LEGAL
DESCRIPTION LOT NO. OWNER v
MAIL
BLOCK TRACT ADDRESS
NO, OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP BK MAP PG''j� �G SSED BY
BUILDINGS /,
CONTRACTOR
4 /C / 6 P31
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ADDRESS CONNECTION DATA It
/ ^ STATION DEPTH
CITY TEL. C
❑ STATE MANHOLE REFERENCE A _
REGISTRATION NO. ❑ COUNTY TZ ) LOWER
NO I DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER 55.00 d
P.C.NO. O
AND/CR SEPT .SEEPAGE PIT OR CO. IMP.NO. JOB NO.
PITS qNDR DRAINFIELO ® SI0.00 A _V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO./ b b0 w
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLOC.OR AFFIDAVIT uv O u5[v[xr PECORD. IN3TR.NO. DATE 0
W ORK TO HOUSE SEW ER 53.00 V
OVERFLOW SEEPAGE PIT.GRAINFIELD W
1
E%TN.,C ES SPOOL.D ABANDON HOUSE � f5.00 HWY.OR ST.WIDENING N
ALTER.flEPAIR OR ABA NOON HOUSE Z
SEW ER OR DISPOSAL SYSTEM ® 53.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
W45TE APPROVAL
AM17
OWNER'S PES z o0 CHARGES
AUTHORIZATION I TOTAL FEE k7
CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBUR5EMENTFEE
TRACTOR TO CONNECT THE ABOVE D CRIBEO E%I ING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY O 19_
OWNER ORNEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL I I
ADDRESS BUILDING OR WORK
BE TIC I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION A.D/OTANK,S IELEP,PIT IB)
AND/OR GRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW CESSPOOL ❑ pRYW ELL ❑
I HEREBY CE FY T T 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS EpUIRE BY LOS ANGLES COUNTY- NO STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN I4 P MAT AM THE LEGA RES OZA' D INTEND TO DISCONNECT PLUG ANO
RESIDE IN, 400 DESCRIBED ENTI L P PERTT.
g BwNOON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERM SEEP.PIT IS) ❑ CESSPOOLS ❑
c7VALIDATION ROBERT WOOD
C RK. M.o. �/.cw✓H J SUPERVISING MECHANICAL ENGINEER
A, ,:JO 3 0 6 APR 6 1 0 D 7.0 0
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