HomeMy Public PortalAbout9318 1/2 BROADWAY_Sewer__ °A542D'°E APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BDILDIN ^'
ADORES IZ O A
IDBN A.A.
JENSE, County f quil i Q C_
' WILLIAM A. IEN$ER, Supt o7 Buildiv0
LOCALITY
NEggEST
FOR APPLICANT TO FILL IN RD35 5T.
LEGAL
DESCRIPTION LOT NO. ( OWNER K
�"' e MAIL
BLOCK TRACT ` AGGRESS
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT CITY TEL.-NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
.Z B(yK PG
CONTRACTO .,+�E. SG. V\t � 11Is /T. J� L�
ADDREssq II,t15 CONNECTION DATA
5 ATION
CITYT/E,L .NIG. �pI{
ATE
.REGISTRATION N� Y [ Ll COUNTY MANHOLE DEFERENCE /� UPPER
NO, DESCRIPTION OF WORK FEE TLENGTH FROM
ONNF�CTI d
HOUSE SEWER CONNECTING TO Y. P.L. M.L.TO P.L. O
PUBLIC SEWER ® 33.00
SEPTIC TANK.SEEPAGE PIT OR P.`.NO. UPITS AND/OR GRAINFIELD ® 310.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO •
THUNK PERMIT NO. ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM $3.00 F
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVHI ASEKERT RECORD.INSTR.N O. DATE W
WORK TO HOUSE SEWER 33.00 CL
OVERFLOW SEEPAGE PIT.GRAINFIELD En
EXT N..CESSPOOL.DRYWELL.MANHOLE 0 33.00 Z
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPP SAL SYSTEM ® $3.00 STATE ENCROACHMENT
PERMIT NO.
l3 OIJ INDUST
WASTE U
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION I TOTAL FEE , O CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF19_
OWNER OR A //A NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC GRAINFIELANK.SEEP.D PITIS)
AND STATE THAT THE ABOVE 15
CORRECT AND AGREE TO COMPLY 'END/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 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 I M THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE AS VE DESCRIBED ES TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PEPMITTEE BACNFILL SEPTIC TANKS ❑
SEEP,PIT IS1 ❑ CESSPOOLS ❑
- /1VALIDATION ROBERT A. WOOD
/ M
CK.K. M.O. CASH SUPERVISING MECHANICAL ENGINEER
L;AC01 0 0 5G OCT 4 1 1 0 . 2 5.00~ Q
71i� 11-7
CE80810-B3
7eAB42D RAPPLICATION FOR PEMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL IIIJII
DEPARTMENT OF COUNTY ENGINEER
.BUILDING AND SAFETY DIVISION BUILDING -
JOHN A, LAMBIE, County Edgin..r ADDRESS
WILLIAM A. ]ENSEN. Supt of Building -
LOCALITV
NEAREST
FOR APPLICANT TO FILL IN CHOSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT m� � � ADDRESS
NO. OF FLOGS.
SIZE OF LOT NOW ON LOT CITY TEL..NO.
USE OF
BUILDINGS DISTRICT NO, GROUPMAP ESSEO BY
..// T �/ K �J.PG�{
/
tiCONTRACTOR �. S/1/C�/ K S/ &o INP ,�J
'ADDRESS /` -yf7,q .(w CONNECTION DATA
T.I. TATION
CITY TQ NO. I� (p J /.�
IML OUNTSTATE UPPER
REGISTRATION NO. ( CY MANHOLE REFERENCE - ^
'NO. DESCRIPTION OF WORK EE [� TYPE F CON C LENGTH FROM •® a
PUBLIC SEWER USE SEWER CONNECTING TO @ $5.00 J OO Y P L P.C.NO:L.TO P.L.
3 O
SEPTIC TANK.SEEPAGE PIT ORZ JOB NO.
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO.
C
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT N O
PRIVATE DISPOSAL SYSTEM ® 43.00 F
CONNECT ADO ITIONAL BLDG.OR AFFIDAVIT I WUVIA s[.[ gECORO. INSTR.NO. DATE W
WORK TO HOUSE SEWER @ $3.00
l
OVERFLOW SEEPAGE PIE DRAINFIELD
ALTER.
0 OABANDO MHOUSE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT
PERMIT NO,
WASTE A J
CHARGES
OWNER`S PERMIT a z 00
AUTHORIZATION TOTAL FEE f[� CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. _ APPROVALS DATE INSPEOTOR'SISIGNATURE
SIGNED THIS DAY OF t9_
OWNER OR �J� :el NEW HOUSE SEWER �]✓ `J•'J / j1�fn� Ji
OWNERS AGENT (JfL ��i.. - - -- .
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.S CEP.PIT(S)
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN0'STATE THAT THE ABOVE. I5 CORRECT ANO AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/ORALTER.RE PAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE-IN, THE.ABOVZIESCRe RESID TIpL PR ERTY.
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
' SEEP.PIT(S) ❑ CESSPOOLS ❑
ALM.0. _ ROBERT A WOOD -
Ur SUPERVISING MECHANICAL ENGINEER
CK. M.O, CASH
LI,t 1 0 0 4G OCT 4 1 0 D . 7.Q0-., x 6