HomeMy Public PortalAbout9320 BROADWAY_Sewer__ K-SD
5& APPLICATION FOR PERMIT ��s
e @ 0420 11�98
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOB Angeles BUILDING �] _
JOHN A. LAMBIE. COUNTY ENGINEER ADORES$ 7-
® CASSATT D. GRIFFIN. SUPT op BUILDING ' LOCALITY
FOR APPLICANT TO FILL IN
NEAREST
aoss sr.
LEGAL
DESCRIPTION LOT N0. =ADDUSS
g
BLOCK TRACT/ G NO. OF SLOGS. TEL. N0.
S12E OF LOT NOW ON LOT USEOFGROUP MAP
BUILDINGSBK PCONTRACTOR � � _J�
ADDRESS x {I ,} CO CTION
A
CITY L �u u� TEL. NO. �'� A y//e r STATION DEPTH
1 MANHOLE REFERENCE PPER
REGISTRATION NO, COUNTY I
2
No. DESCRIPTION OFWO(TK >/ FEE
TYPE OF CTION LENGTH FROM
HOUSE SEWER CONNECTING TO l' Y. URB P.L. M.L.TO P.L. `} .`s
PUBLIC SEWER @ $3.50 �{, LX--�+
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELDP.CO. IMP. NO. �, � JOB NO.
OVERFLOW
SE OL,DRY IT. DRAT N TELE � $2.00 p/''j
ER
PRIVATE DHOUSE ISPOSAL SYSTEMG TO @ $1.00 TRUNK PERMIT NO. ROAD PaIT NO.4?15
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
d APPROVALS DATEINSPECTOR'S SIGNATURE
I HAVE AT THIS DATE AWITH THE HEREIN NAMED N-
TRACTOR TO CONNECT THEHE ABOVE
DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19_ 'CONNECT ADDITIONAL
OWNER OR ® J 'R&77 < BUILDING OR WORK
OWNERS AGENT_ /,�] V•� SEPTIC TANK,SEEP, PIT(S)
' ADDRESS DAO, ( r�(�:NR 1 `� ' .) C AND/OR DRAINFIELD
AND STATE THAT HEREBY ACKNOWLEDGE
ABOVE ST I HAVE CORRECT RAND AGREE OLM POLY CESSPOOLE3 ORYW ELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
' PLUMBING AND SEWERS. SEWAGE DISPOSA L SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEG OWNER OF THE ABOVE
DESCRIBED RESIDENTIA ROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTFP
JOHN A. LAMBI.( •NTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
U.0. CASH
J& 4957DEC 9 4 45 0