HomeMy Public PortalAbout9423 BROADWAY_Sewer__ al;Ee 311;33` APPLICATION FOR PERMIT. 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL +
Deportment of County Engineer UIL
County of Los Angeles sIDRE S -O _.
JOHN A. LAMBIE, COUNTY ENGINEER "ADDRESSi+�I/`Cu
® CASSATT D.GRIFFIN, SUPT OP BUILDING LOCALITY
FOR APPLICA TO L CROSS ST.
LEGAL
DESCRIPTION I " T N0. OWNER �T
AIL
BLOCK - TRACT`7.,. in.I�(c}C� /f��,t.� p DRESS Q
NO. OF BLDGS. - CITY TEL. N0.
SIZE OF LOT, NOW ON LOT
USE OF - OISTRICT•N0. GROUP MAP PG
BUILDINGS -/'
CONTRACTOR �) I �_ C.•d N `i J A� � -.1BK
ADDRESS � ✓ CONNECTION DATA U- '
�9 STATION .� DEPTH
CITY A TEL. N0. i'
/'� MANHOLE REFERENCE
[lI.H-FATE � A LOWE _
REGISTRATION NO. > 7/ ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF.CQRAEKyOf LENGTH FROM
CURB M.L. TO P.L, i
_ PUBLIC SEWER @ $3.50 (J tz
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD /;L(�I_ -:j P. C NO
@' . -
EXTN..CESSPOOL.DRYWELL.MANHOLE $ 2.00 CO. INP. N0. /`- JOB NO.
-HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. /' Y
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT r
WORK TO HOUSE SEWER ' @ $ 1.00 PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL r
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL '
CHARGES .
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE r
AUTHORIZATION TOTAL FEE y 5 n,
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED,CON- APPROVALS DATE INSPE TORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF- V 19CONNECT ADDITIONAL
OWNER BUILDING OR WORK
OWNERS AGENT - - TIC TANK,SEEP, PIT(S)
ADDRESS r Y'-C. �A WOR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I, 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RECUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM HE LEGAL OWN OF THE ABOVE '
DESCRIBED RESIDENTIAL PR PTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE _OF PERMITTEE
JOHN A. LAMBIE, COU ENGINEER _ =VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
(/ CKK. N.0. LASH ' A
4.50
• LIG18.6-.4Y .AUG30 4
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