HomeMy Public PortalAbout9444 BROADWAY_Sewer__ 0 - APPLICATION FOR PERMIT
44466DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer I- - -
County of Los Angeles BUaDING //
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS "/ '/ / y �1 t ylZ.e k
® CASSATT D. GRIFFIN, Suv'i oFBwLOIrva 1: LOCALITY, ? ,
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FOR APPLICANT TO FILL IN CROSS ST.
LEGAL W; O r OWNER
DESCRIPTION LOT NO;5w
j'j 1
MAIL
BLOCK TRAC � ADDRESS
SIZE OF LOT . _ CITY Lp��.J2 - TEL. N0..
USE OF ,DISTRICT NO. GROUP MAPBUILDINGS BK PGCONTRACTORADDRESS ZSW 13fyjji �rR y/ CONNECTION DATA
CITY
&k tKO✓ f' TEL. NO" It/ STATION 1 ( DEPTH
J yf MANHOLE REFERENCE-9 TATE
REGISTRATION NO. / L COUNTY r�(I VV LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION -LENGTH FROM /
HOUSE SEWER CONNECTING TO ��jj n CURB P.L. M.L.TO P.L. �J
PUBLIC SEWER @ $3.50 J a
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. N0. 12 (, L 308 NO.
HOUSE SEWER CONNECTING TO 67 �f
PRIVATE DISPOSAL SYSTEM @ $1.00 'TRUNK PERMIT NO. ROAD PERMIT NO. ` G
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $I.DD PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 DO
AUTHORIZATION TOTAL FEE
Y SQ REIMBURSEMENT FEE
' I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED"cow APPROVALS DATE IN SPECTOR'$SIGNATURE,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC.SEWER. NEW HOUSE SEWER - ��
SIGNED THIS-- OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK -
OWNERS AGENT L/ /1A�(/
✓ SEPTICTANK,SEEP, PIT(S)
ADDRESS- 'AND/OR DRAINFIELD
I 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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONABANDON HOUSE SEWER
CALIFORNIA OR THAT I d THE LEG - OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP, PIT(S) ❑ CESSPOOLS
OF PERMITTE
JOHN A. LAMBIE. C NTY NGINEER VALIDATION ROBERT A. WOOD, CHIEF PLSG. INSPECTOR
CK. M.O. CASH -
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