HomeMy Public PortalAbout9314 BROADWAY_Sewer__ C-6D
S& 63 II�33 APPLICATION FOR PERMIT 5
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL iNS
Department of County Engineer -
County of Los Angeles BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FriALICANT TO FILL IN 'R
PPoss ST.
LEGAL / OWNER '
DESCRIPTION LOT N0. ('/`7
MAILj r
BLOCK TRACT �"((J� i(J ��G ADDRESS
2 NO. OF SLDGS. CITY TEL. N0.
SIZE OF LOT 3 �OW ON LOT
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
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I CONTRACTOR J ^ / ...BK / .9
3
ADDRESS
�t CONNECTION DATA
nn STATION DEPTH
CITY m NO. MANHOLE REFERENCE _ UPPER
❑ STATE A LOWER
REGI TRATION NO. ❑ COUNTYCEZX •O 1 Q'y
NO. DESCRIPTION OF WORK FEE / I /
HOUSE SEWER CONNECTING TOTYPE OF CONNECTIO LEP4TH FROM
PUBLIC SEWER @ $3.50 Y. CURB L. AVL. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT, GRAINFIELD P. C. NO.
EXT N..CESSPOOL,ORYW ELL,MAN HOLE Q $2:00 CO. IMP. NO. OB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S 1.00 TRUNK PERMIT NO. R D PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMEN <
WORK TO HOUSE SEWER Q $I.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s I oo
AUTHORIZATION TOTAL FEE REIMS URSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA;2961( APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING Lout .
TO THE PUBLIC SEWER. NEW HOUSE SEWER
( SIGNED THIS�-�—DAY OF /2I9
CONNECT ADDITIONAL
OWNER 'OR BUILDING OR WORK .
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL Q.,
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 I AM PROPERLY REGISTERED AND/Oft PLUG AND
DISCONNECT
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGD
CALIFORNIA OR THAT I AM' THE LEG WN F THE ABOVE
DESCRIBED RESIDE AL P BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHNA. LAMB111 OUNTY ENGINEER VALIDATI ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CM.
M.0. CASH
}A[I0,1r8:2 3AUG29 4 2.00