HomeMy Public PortalAbout9238 BROADWAY_Sewer__ fi 8fij71 83 • APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING q
JOHN A A.A.
JENSE, County Engineer ADDRESS J
WILLIAM A. JEN$EN. Sup'1 0! Building
Louury
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
M414
BLOCK TRACT ��/y/ /_ /]] /� AOD REBS
E.
SI2E OF LOT NOW ONN LOT CITY TEL. NO,
USE OF DISTRICT NO, GROUP MAP PROCESSED BY
BUILDINGS
J BK PG
CONTRACT `J /O 13 3
ZLe
ADDRESS,. �c c s� CONNECTION DATA
CITY O. 90 STATION DEPTH
R STATEMANHOLE REFERENCE UPPER
REGISTRATION NO. LJ COUNTY LOWER
FNO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. r
PUBLIC SEWER 55.00 P.C.NO. CIL
SEPTICTANK.SEEPAGE PIT OR JOB NO. O
PITS ANO/OR DR4INFIELD @ SI0.00 Co,I.R. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® $3.00 �.
CONNECT ADDITIONAL BLDG.OR ,^ AFFIDAVIT I W.11111 I 1411M Ni RECORD. INSTR.NO. DATE Q
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL.DRYWELL.MANHOLEQ $5.00 y
HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE yI
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z o0
AUTHORIZATIONI TOTAL FEE ! CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF f
OWNER OR
NEW HOUSE SEWER A
OWNERS AGE
CONNECT ADDITIONAL
BUILDING OR WORKSEPTIC
ADDRESS
I HEREBY ACKNOWL OE THAT I HAVE READ THIS APPLICATION A.D/OTANK.SEER PIT 151
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT IAM THE LEGAL OWNER OAND SENO TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DES,18J✓Lp RE IAL F,PRO TY'. ABANDON HOUSE SEW ER
SIGNATURE /C BACKFILL SEPTIC TANKS ❑
OF PERMIT ❑
SEEP,PIT IBI ElCESSPOOLS
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CH. M.O. CASH
LtiLo 3 8 5 8 2? MR 2 9 1 0 D 5L011
TGAE<3D - APPLICATION FOR PERMIT
•6 E-363 3.1E
DIVISION OF BUILDING AND SAFETY SEWED—SEWAGE DISPOSAL
Depm'tment of County Engineer
County OI Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
'® CASSATT O. GRIFFIN, SUP'TOF BUILDING LOCALITY y!-p�
FOR APPLICANTTO FILL IN- NEAREST _ e
CROSS ST.
LEGAL Q.
DESCRIPTION LO NO 7 �Y ! OWNER
- AIL
BLOCK TRAIT l(I• p0 RES, �q' Q
SIZE OF LOT • NOW ON 40 CITY 4- TEL. NO.
NO. OF BCDGS.
USE OF
BUILDINGS / DISTRICT 110. GROUP MAP
BK PG
CONTRACTOR 1�) I T p 22
ADORESITs — J 1 IZCONNECTION DATA ' ✓
CT ' TEL. R.!T J L- STATION la-f /6, n DEPTHSTATE I,• q
REGISTRATION NO, / 2— 6 9_3j- COUNTY MANHOLE REFERENCE / /' � LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ,.�0 TYPE=NCCTION LENGTH FROM ✓J�f
Y. CURB P L R1 L TO P.L.
....CC
_ PUeLIC SEWER @ $ 3.50 _
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADD'
TIONAL BLDG. OR .f P. C. N0.
_ WORK TO HOUSE SEWER LOO CO. IMP. NO. f,L�• JOB NO.
ALTER OR REPAIR EXISTING ^`r
SCWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0. J34
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ ANO/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK. SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- ORYWELL WASTE APPROVAL ,Y
SPECIAL CONDITIONS ONLY 2.00 CHARGES`
PERMIT $ 1 00 CONNECTION CHARGE FEE . '\
OWNER'S \
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRI E%ISTING OW FEEING _ APPROVALS GATE INSPECTOR'S SIGNATURC
TO THE PUBLICS EWE
_
A NEW HOUSE SEWER
SIGNED THIS DAY OF 19� � '-�-t"'--�• t) .1.• _._._._.
OWNER OR CONNECT ADDITIONAL
OWNERS A NT BUILDING OR WORK
SEPTIC TANK, SEEP, PITS)
ADDRESS _a=te AND/OR GRAINFIELD
I HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS AP LIGATION CESSPOOL❑ DRYWELL❑ '
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
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❑
I ] SEEP. PIT(,) FI CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R.A. WOOD. CHIEF PLEG. INSPECTOR
Y JJT41 3 1 6 DEC 29 4 4-5-0