HomeMy Public PortalAbout9336 BROADWAY_Sewer__ 6420` 12-54 I..I'E-6D
5& APPCATIOWFOR PERM T
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County .Engineer
County of Los Angeles kDDRESs
WM. J. FOX. COUNTY ENGINEER
CASSATT O. GRIFFIN. SVP,oF.BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
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CROSS ST
LEGAL 'DESCRIPTION LOTNO. z LU /
OWNER CA-4.,c
MAIL MAILBLOCK TRACT T-r Hae I '
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ADDRESS ry--�•!h
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SIZE OF LOT x"�'s X � d S NOW ON LOT'BLDGS. � '
CITY .TEL. N0.
USE OF A LCI, �S C/I-�cT AP
BUILDINGS a I DISTRICT NO. GROUP MAP
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ADDRESS Lr Pp G /L'•C' i �lr c /.(� a CONNECTION DATA
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CITY �A ,eL<t� a TEL. 0. 6 G, 5'� STATION 9 V4 Ay� ss DEPTH r -
NATE / i �+0 � / MANHOLE'REFERENCE
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REGISTRATION NO. C- / V El COUNTY /»•YY Nf _11ABER LOWER
TYPE OF CONNECTION LENGTH.FROM
ND. .DESCRIPTION OF WORK - .FEE CURB _ EL. M.L. TO P.L. 0I,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER - Q $- 3.50 �O
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR l� Co. . Q./ 9•
WORK TO HOUSE SEWER I.Do C7 COIMP
0 ,. N0 �nd /Ar JOB, N0.
ALTER OR REPAIR EXISTING x
--.SEWER OR DISPOSAL E SYSTEM - 1.00 TRUNK PERMIT NO. ROAD PERMIT N0. V < �•
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ ANO/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
'PERMIT CONNECTION CHARGE FEE
OWNERS $ 1 �00
AUTHORIZATION TOTAL FES' J D' REIMBURSEMENT FEE
I HAVE-THIS DATE CONTRACTED WITH ..THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED'EXISTING DWELLING APPROVALS GATE INSPECTOR'S SIGNATURE'
TO THE PUBLIC 'SEWER _ CC
SIGNED THISDAY OF / d 19l✓r NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS A ,NyT ��-'>•'�+ -/'/ BUILDING OR WORK _
S 'Z (_ /5 Y.X d�4r b Y SEPTIC TANK, SEEP, PITS) -
ADDRESS AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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 -
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ECT'PLUG AND
ON
DiSCN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF iDISC ON HOUSE SEWER •
CALIFORNIA OR THAT. I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. - ,BACKFILL SEPTIC TANKS[]
U1, I" -F�/S ('" SEEP:PIT(S) ❑ CESSPOOLS �•�
SIGNATURE
OF PERMITTEE -
WILLIAM J. FOX, COU Y ENGINEER VALIDATION
er Com aYs .y� Mmr1.0 4 5.50 ,
` - DEPUTY DEPUTY'`
By By
'® DEPUTY' //'� DEPUTY