HomeMy Public PortalAbout9404, 9400-9404 BROADWAY_Sewer__ 4650 INSERTS//
CE8086-00 APPLICATION FOR PERMIT y
PSAsazD COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION nooaElssG x/00— V4 F &APADivW. _
TORN A. LAMBIE, Couvfp E. 'no
WILLIAM A. JENSEN, Supt of BuHdL7 LOCALITY U2 S' G
. - - - .. .• - NEAREST
FOR APP LIC TO FILL CROSS ST. ES
LEGAL
, DESCRIPTION LOT N0. OWNER
BLOCK TRAC MAIL
ADDRESS
)�
SIZE OF LOT GP 31k 20 NOWOF ON SLLOOTGS. CITY TEL. N0.
USE OF ,pw — - -
'BUILDINGS y— DISTRICT N0. GROUP MAP CEBSEO BY
CONTRACTOR �K P� Ir' �i
ADDRESS ../ ! CONNECTION DATA
CITY �� TEL.NO/ STATION S DEPTH
�{/�RK �r STATE MANHOLE RE ERENCE UPPER
REGISTRATION NO. �,/ % / B COUNTY -
NO. DESCRIPTI NOF WOFEE
HOUSE SEWER CONNECTING TOig
PUBLIC SEWER @ S3.00 VffPE OF 1 LENGTH FROM c�
X
SEPTIC TANK,SEEPAGE PIT OR Y. URB CTION P.L:
PITS AND/OR GRAINFIELD @ $3.00 �
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $
2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOR N0. „
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. O
WORK TO HOUSE SEWER C@ $1.00 U
SEWER OR 0,R A8ANDM SYSTEM HOUSE @ 51 00 STATE ENCROACHMENT
PERMIT NO. p
INDUSTRIAL V
WASTE APPROVAL M
_ CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. / �(�Ib&1
SIGNED THIS DAY OP_ 19_ NEWHOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT �J✓ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - -
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL ❑
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 Y LOS ANGELES COUNTY ANO STATE _ ABANDON HOUSE SEWER
CALIFORNIA OR TH AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE 1 PROPERTY. BACKFILLSEPTICTANKS ❑ 1/„Z� ? /J '�i
SIGNATURE SEEP. PIT(S ❑ CESSPOOLS /
OF PERMITTE
®F VALIDATION ROBERT A. WOOD
cm. M.v, usH SUPERVISING MECHANICAL ENGINEER
LAL'o NT, D