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HomeMy Public PortalAbout9419 BROADWAY_Sewer__ C EBOA.10.62 APPLICATION FOR PERMI TBA642D COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BDILm.. JOHN A. LAMBIE. County Engineer ADDRESS A WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL OESCRIPTI ON LOT NO //10� Q G OWNER SSC L MAIL BLOCK TRACT /ff/O/+ ��L✓ CI^�.J ADDRESS 1 } NO. OF SIZE OF LOT •g y 4) NOW ON LOT / CITY I.L. NO. USE OF BUILDINGS DISTRICT NO.1 GROUP1 MAP PROCE EtO BY BK PG CONTRACTOR //✓ / O� 5 / — ADDRESS 7p /v �/ © CONNECTION DATA CITY TEL. NO. STATION DEPTH / ❑ STATE UPPER REGISTRATION NO. ❑ COUNTY MA OL EF EN LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM } HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. O PUBLIC SEWER E5.00 P.C.NO. V SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR GRAINFIELD SI0.00 CO.IMP. NO. JOB NO. � HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O PRIVATE DISPOSAL SYSTEM $3.00 F CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WRIVE, suds RECORD. NSTR.NO. DATE W / WORK TO HOUSE SEWER $3.00 a OVERFLOW SEEPAGE PIT,DRAINFIELD 1A EXT N..CES5POOL.DRYWELL.MANHOLE@ E5OO Z ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING SEWER OR DISPOSAL SYSTEM- @ 53.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS _ EAMI7 s z 00 AUTHORIZATION TOTAL FEE U9 CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR5 SIGNATURE SIGNED THIS DAY OF 19_ / OWNER OR NEW HOUSE SEWER f l OWNERS AGENT CONNECT ADDITIONAL / BUILDING OR WORK S V43 ADDRESS v SEPTIC TANK.SEEP.PIT(5) f HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION gryD/OR GRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR LICENSEO AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO 1015CONNECT PLUG AND RESIDE IN. THE ABOVE. OESCR BED IOENTIAL P OPEN T ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE / BACKFILL SEPTIC TANKS ❑ ❑ SEEP.PITISI ❑ C SPOOLS ALN ROBERT WOOD M.0. cK. ) M.D. CASH �/I SUPERVISING MECHANICAL ENGINEER �ll�� 5 1 4 4 4 FYty 2 3 1 0 D 5.0 0— s TaA°A2° caeoe a-aa APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEEEI BUILDING AND SAFETY DIVISION nooses"sG D ]OHN A. LANSIE, County En e.r ClATT D. CNFFQI, Sup t of Building LOCALItt NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL �QC DESCRIPTION LOT NO. OWNER Z BLOCK TRACT ✓llII MAIL f i j"W ADDRESS V NO.OF BLDGS. SIZE OF LOT6 O X � NOW ON LOT CITY TEL. N0. USE OF � BUILDINGS DISTRICT NO. GROUP BK MAP PG P pCE53E BY CONTRACTOR 5_ ✓ I� — Q`I �I ADDRESS f tic NC r/ j'� , CO JNNECTICO7N DATA((( CITY ;�—_7• 79 EL.NO. b STATION 3 ` G_Q DEPTH 3 REGISTRATION N0. /> 7 —r—l/ STATE MANHOLE REFERENCE f LOW/ LOWER NO. DESCRIPTION OF WORK FEE / HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTIO LENGTH FROM PITS AND/OR DRAINFIELD @ $3.00 Y. CURB .L M.L.TO P.L. � OVERFLOW SEEPAGE PIT.OR - A, EXTN..CESSP00 L.D RYWELL @ $2.00 p V6 HOUSE SEWER CONNECTING TO P.C.NO. _ PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO. WORK TO HOUSEISEWER LOG.OR @ S1.00 TRUNK PERMIT NO: ROAD PERMIT NO. ALTER, RE P AIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $I.00 PERMIT NO. .INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT § Z UU CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE -9a 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 SEW R SIGNED THIS DAY OF 19 NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL `. OWNERS AGENT BUILDING OR WORK u SEPTIC TANK,SEEP.PIT(S) ADDRESS AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I IFAVE READ THIS AFNkMATION ' AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING I PLUMBING AND SEWERS. ALTER',REPAIR,SEWER OR SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REG TERED NO OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY S ELESUNT ANOATE OF ABANDON CTPLUGHOUSE ANDCALIFORNIA T I EGWER NE OF E ABOVEDESCRIBE ESIDENT LP OP TY. SEEP.BACKFILL (S)PTIC TANKS ❑ CESSP00❑LS �� SIGNATOR OF PERMITTE ®' ALIDATION ROBERT A. WOOD CK M.o. CASH SUPERVISING MECHANICAL ENGINEER LC a1 0 8 2 ;'E'lr2 0 1 0 A 5.00