HomeMy Public PortalAbout9328 BROADWAY_Sewer__ J
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C66 APPLICATION FOR PERMIIT-
$eDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer - -
County of Los Angeles BUILDING !w
JOHN A. LAMBIE, COUNTY ENGINEERADDRE
C: SS Oy
® ASSATT D: PLOCALITY
GRIFFIN, SUPT OF BUILDING
(
FOPPLICANT TO FILL IN caoss ST
R A . .
LEGAL
D OWNERS-
. CRIPTION LOT N0. _
C TROT _ n ADOR ESS ](�.�A// _ t.-s /✓� , n�/IA7
[' �Hb.OF BLDGS. !'
CITY
SIZE OF LOT JI NOW ON LOT .n.,tA,t�V n .(Q TEL. N0.
USE DI DISTRICT NO. GROUP MAP
BUILDINGS
BK PG
CONTRACTOR �;•Q J
ADDRESSS ' / CONNECTION DATA
/A/
STATION S DEPTH v
CITY L. 1
MANHOLE REFERENCE �1 _
Jam/ ❑ STATE
REGISTRATION N ❑ COUNTY
NO. DESCRIPTION OF WOR( FEE TYPE OF flu uFCTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y /,CU !(J P L M L TO H P.L.
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PUBLIC SEWER @ $3.50 _ (._.�
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD (gl $3.00
C.
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. NO. �� POB N0.
EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TOHOUSE SEWER
SYSTEM @ 31.00 TRUNK PERMIT N0. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $L00 WASTE APPROVAL - -
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ I 00 ^
REIMBURSEMENT FEE
AUTHORIZATION TOTAt FEE (/
1 HAVE AT THIS DATE A CONTRACT WIT}J THE HER NAMED con- APPROVALS DATE INSPECTOR 3�_ N'ATUlRE
TRACTOR TO CONNECT THE AB tIFSJCRIBED EXISTING DWELLING
TO THE PUBLI SEWER. W&{/{_ `(Y'�!W"� j�/.(}l NEW HOUSE SEWER �!
SIGNED THIS DAYKJF tY} � CONNECT ADDITIONAL
OWNER OR n BUILDING OR WORK
OWNERS AGE �N .Tp/)'. �.�f7 1
SEPTIC TANK,SEEP,PIT(S)
ADDRESS "4^S �� -'T'-7 ��4AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
' 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
I 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 THE LEGAL ER OF THE A VE -
DESCRIBED RESIDENTIA OP.ERTYi BACKFILL SEPTIC TANKS❑ /
SIGNATURE . // SEEP. PIT(S) ❑ CESSPOOLS t (/
OF PERMITTEE v �--'�� .�t
JOHN A. LAMBIE. COUNTY ENGINEER -VALIDATION ROBERT A. WOOD.CHIEF PLBG. lWgPECTOR
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LAC.0 2 '2"7'2r JAN 8 - 4 A 5-5.0 M