HomeMy Public PortalAbout9517 BROADWAY_Sewer__ 12-56-66
&E�66�! APPLICATION, FOR PERMIT. 1
i 5 h
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer c
County Of LOB Angeles BUILDING G
} WM.J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN.SUPT OF BUILDING LOCALITY 3
FOR APPLICANT TO FILL IN NEAREST
/ [� CROSS'ST.
LEGL
DE CRIPTION LOT NO. EI (1 7/Q F S A
OWNER
�Q a- MAIL
Bf®RQF�OT//I RACT • r�[rG./ ADDRESS
t[" N0. OF BLOGS. /
512E OF LOT 7 NOW ON LOT CITY
USE OF e
' BUILDINGS DISTRICT NO. GROUP MAP
CONTRACTOR • S � D �Ki3 PG
ADDRESS J� QC.ONNECTION DATA T
CITY �-- TEL. N0. STATION T- 7,6's- DEPTH R�
❑ STATE ;T! T_ M EFERENCE
REGISTRATION N0. / •-� �OL ,ET"'^" y �L.S mil UPP LOWER
TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK - FEE -Y. CURB P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO
HOUSEPUBLIC SEWER (B) S 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP.NO./2 v JOB. NO.
_ WORK TO HOUSE SEVIER 1.00
ALTER OR REPAIR EXISTING 3 1 ss
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. ROAD PERMIT N0, Z S p
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
ANO/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION 2oTAL EEE / REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- .
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE IN PECTOR'S SIGNATURE
TO THE PUBLIC SE ER.�yr
/fv�X NEW HOUSE SEWER
SIGNED THIS1 G—DAY OF 19v T
OWNER' OR "�P CONNECT ADDITIONAL
OWNERS AGEN _BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
'ADDRESS - AND/ORDRAINFIELD
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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
- J SEEP. PIT(S) ElCESSPOOLS 0
SIGNATURE V -
OF_PERMITT
WILLIAM J.-FOX, COUNTY ENGINEER VALIDATION
ya �202;r;e JAN18 4 4.50 In
BY BY _ --
DEPUTY �DEyPPUUTTYYp
i® DEPUTY T DEPUTY