HomeMy Public PortalAbout9330 BROADWAY_Sewer__ 0
CESOB APPA FOR PERMIT To 9330 _NaRrEn�Y
aaoe a-ea COUNTY OF LOS ANGELESUN'f
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bm LDING
A. LAFIDIE, CountEvqiveer 3 G r^
- ADORES, F- 4;'A 49 WA
}OHN y
CILSSATT D. GRIFFIN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CHo„ ST.
LEGAL r
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
N0,
OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF pems'
BUILDING, DISTRICT NO.I GROUPI MAP I�PROCE'
J' K PG
CONTRACTOR D 1 3�
ADDRESS f' CONNECTION DATA I
CITY L TEL.NO.,/_ Q STATION -TL DEPTH
REGISTRATION NO.
3 TJ a CSTATE OUNTY MANHOLE REFERENCE UPPER
L
NO. DESCRIPTION OF WORK F
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 O G TYPE OF CONNECTION LENGTH FROM C
PETS ND/OR DRAINFPTIC TANK. GE DIT OR @ ,3.00 Y. CURD P.L. M.L.TO
OVERFLOW SEEPAGE PIT,DRAINFIELD
_ EXTN,.CESSPOOL. DRYWELL
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ E1.00 CO.IMP. N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR
ORK C HOUSE SEWER @ TRUNK PERMIT NO. ROAD PERMIT NO.
W $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PEANAT S 2 UO CONNECTION CHARGE FEE
AUTHORMATIO r REIMBURSEMENT FEE p�I// nCY'lL
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- - /V�J n�.n >
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.SIGNED -
OWNER O THIS F 19_ - NEW HOU ADDITIONAL SEWER T/�+• ,��� - !n�/)N/.'
OWNER A Y,��. ,J/ CONNECT A OR
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGDISCONNECTPOSAL AND
EM
LICENSED AS REOUI RED BY LOS ANGELES COUNTY AND STATE OF ABANDON PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT A PROPERTY. BACKFILL SEPTIC TANK, ❑
SIGNATURE SEEP. PITIS) CESSPOOLS
OF PERMITTEE
®a VALIDATION ROBERT A. WOOD
CIL M.D. CASH SUPERVISING MECHANICAL ENGINEER
X01 5 9 7 "!A 1 1 G D 5 .0 G
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