HomeMy Public PortalAbout9523 BROADWAY_Sewer__ DEFARTIFffiNT OF COUNTY ENGXNI= SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELE8'
WILLIAM J. FDX, COUNTY ENGINEER I I BUILDING/ieZ�?
FOR XPPLIOX ADDRESS 7
�/ S� J N L�
[NEAREST
�C_
BUILDING 1ADDRESS iLOCALITY + T N0. Reatly for InsOec(ion PERMQI'TC�N•0. rNEAREST _ }- O /� JCROSS6Tol D;BV DATE ISSUED•BY DATE-
OWNER `•. �MAIL
ADDRESS •EY OCCUPANCYG MAP
pa
CITY 'g, TELNO. _ �' / /K
�. /3 _ _I
CONTRACTOR �r —L-fL�jyY CO.IMP.N0.
ADDRESS v /9 JOB.NO.
TELAO. TRUNK PERMIT NO. l
REGISTRATION N0. Q O'�/ Q"Jf•H COUNTY ROAD PERMIT NO.
LEGAL
�' 6
DESCRIPTION L0T N0.(�/.J 202 / Q
I7 STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT �..�.S�0�1 ��� (? *WAT
STEAPPROVAL
SIZE OF LOT ,/'(� N0.OF BLOCS.
- Tp/-C p20, �N/O/W ON LOT - CHARGES
USEOF
BUILDINGS CONNECTION CHARGE FE_E
NO. DESCRIPTION OF WORK FEE �-
HOUSE SEWER CONNECTING TO
/+ REIMBURSEMENT FEE X
' PUBLIC SEWER 03 3.50 -� ] D. RECEIPT NO. 'I/ DATE IBY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR /EXCEPTION RECORDED
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING - / NO- I DATE BY
_
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM . 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION/,"'- ,�^'V•p— DEPTH
CESSPOOL—DRYWELL
SPECIAL CGNDITIONS ONLY 2.00 �/ /�I�DtANHOLLREFERENCE
♦5_ ' (UPPER', lLOWER
�TVPE OF-CONN,ECTION LENGTH FROM C�
OWNERS PERMIT S I
,.Y,
\CURB] 1P: M.L.TO P.L. l
AUTHORIZATION TOTAL FEE U
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGNATURE DATE
DWELLING TO T'tE UBLIC SEWER
SIGNED THI$�� _ 0 "I NEW HOUSE SEWER ♦.G..4(/� G /.
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
NERS AGE T.. ..._ ._.. ...__�_.. .. . . ._ -------------
OW
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........... . ......_......_.........._._.._.._.._.._.._...._.._._._...__._.. AND/OR DRAINFIELD
1 HEREBY AC OWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE CRIBED RE i NTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ✓ EEP.PIT(S)C] CESSPOOLS `
OF PERMITTEE.,__. . ....
.....4.�.._.._.__��._.nI ••
IGA642D S&S 663 4/54