HomeMy Public PortalAbout9408-9412 BROADWAY_Sewer__ 44650 INSERTS /
LE2D ° APPLICp(�L ION FOR PERMIT
>sA64psaCOUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL I
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING /
ADDRESS - L
IGRNA. LAMBIE, CouutT Evggineer
WILLIAM A. JENSEN, Supt oI Buildi.9 LOCALITY
I NEAREST
FOR APPLICANT TO FILL IN
CROSS ST.
LEAL
DESCRIPTION LOT NO. 15413,IS•O` 0 1 2 O-r-,-i
4.35 OWNER •
BLOCK TRACTd�/✓, ZBj`' MAIL L•�3 N�ecn 'AO DRESSSw1/iG
NO.OF BLDG VA v
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
o
BUIDINGS S PG
BK
L
CONTRACTOR � _Jr UY Cir 7
ADDRESS ^/„ v C NNECTION DATA
CITY 5 s TEL.NO. Z STATION DEPTH
+ Se STATE MANHOLE REFERENCE - UPPER
REGISTRATION NO. Z��L COUNTY
LOWER
NO. DESCRIPTION OFIRP FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE Of CONNEeirION LENG H FROM
SETS AND/ORPTIC O EEPAGIE PDT OR @ g3.00 Y. CV P. M.L.TOP .
OVERFLOW SEEPAGE PIT. DRAINFIELD �D
EXTN..CESSPOOL. DRYWELL @ $2.00
P.C.NO.
HOUSE SEWER CONNECTING TO CO. IMP JOB NO.
PRIVATE DISPOSAL SYSTEM @ 8I.00 >,
yCONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER C@ SLOO 11
ALTER, REPAIR OSAL SYSTEM HOUSE @ $I 00 STATE ENCROACHMENT
PERMIT NO. O
INDUSTRIAL pHp
WASTE APPROVAL . Wh
CHARGES In
OV✓NER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATIONI TOTAL FEE a 9911 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.
SIGNED THIS DAY 19_ NEW HOUSE SEWER
OWNER CONNECT
ADDITIONAL
A
OWNERS AGENT /v BUILDING OR WORK ��J AGI ,CLFLw.
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY. ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL [I
ITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERT THAT I AM PROPERLY REG EO AND/OR DISCONNECT PLUG AND
LICENSED AS ED BY LOS ANGEL COUNTY D STATE OF ABANDON HOUSE SEWER
CA LIFRN IA AT I AM THE OWNER F THE ABOYE
DESCRIBED NTIAL PROPERTY SEEP.BACKFILL SEPTIC
OD TANKS CESSPOOLS ❑
SI G NA"R
OF PER
® VALIDATION ROBERT WOOD
CK. M.0, DASH SUPERVISING MECHANICAL. ENGINEER
L
lull 4 s 7 :�� 15 "' D 4.00