HomeMy Public PortalAbout9525 BROADWAY_Sewer__ CES06°3.82 APPLICATION FOR PEA MIT, yf�I
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County EDginaev ADDFEss
WILLIAM A. JENSEN, Supt of Boildmg
LOCALITY
NEAREST
FOR APP CANT TO FILL IN FASB ST.
LEGAL
DESCRIPTION LOT OWNER
MAIL
BLOCK TRACT ADDRESS
NO. F BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO. .
USE OF ' DISTRICT NO GROUP MAP PPOC SED BY
BOILOI N GS
CONTRACTO l�0 J
ADDRESS V CONNECTION DATA
f l Q SIA/0N DEPTH S
CITY TEL. NO. /(CFL,I
STATE
REGISTRATION NO. Lf COUNTY MANHOLE REFERENCE COUNTY
L
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION G / LEN G FROM r
HOUBE SEW ER CONNECTING TO Y. CURB 1.L. ML. P.L. O
PUBLIC SEWER @ s5.00
P.C.NO,
SEPTIC TANK.SEEPAGE PIT OR JOB NO {•,)
PITS AND/OR GRAINFIELD lip EI0.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD FERMI NO, O
PRIVATE DISPOSAL SYSTEM Q S3.00 0
CONNECT ADDITIONAL BLDG.OR AFF[ VIT XAIYglt'�gEME RECORD.II N ATE
WORK TO HOUSE SEWER a E3GO
OVERFLOW SEEPAGE PIT.DRAIN FIELD ya
E%T N..CESS POOL,O RYWELL,MAN HOLE 55,00 HWY.OR ST.WIDENIN
10
ALTER,REPAIR OF ABANDON HOUSE V
SEWER OR OI SPOSAL SYSTEM E3.00 STATE ENCROq RENT
PERMIT NO.
INDUSTRIAL
WASTE A A
HARGES
OWNERS PERMIT s zdo
ov
AUTHORIZATION TOTAL FEE /� 7 CONNECTION CHARGE FEE '
ITHAVE AT THIS DATE A CONTRACT WIH THE HEREIN NAMED CON- REIMBURSEMENTEEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR NEW HOUBE SEWEfl
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION pND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DPIWELL ❑
I HEREBY CEFTIFY THAT I AM PROPERLY REGISTERED AND/OR A LTER.REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE BL SEPTIC TANKS ❑
OF PERMITTEE SACKFILCKFILPER ISSEE ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
y.Ay cK. Y M.O. CASH SUPERVISING MECHANICAL ENGINEER
U_COO e 3 7G FEB 6 8 0 D 17 4.100
LI'1CO 0 6 3 8" FEB 6 1 0 D 7.0 0^' 2
V
DEBQ93-s2 APPLICATION FOR PERMI {�
TsgsazD u
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUaOING JOHN A. LAMBIE, County Engineer ADBREss J
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL CROSS ST.
GAL
DESCfl IPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
OF BLDG,
.
SIZE OF LOT NOW ON LOT CITY TEL
NO.
USE OF DISTRICT NO. GROUP MAP PROCE D BY
BUILDINGS
BK PG
CONTRACTOR /
ADDRESS F Q CONNECTIONDATA
CITY TEL. NO,�T)
STATE MANHOLE REFERENCE
REGISTRATION NO. �fL COUNTY LOWER
NO, DESCRIP .TOR FEE TYPE OF ON ON ` LENGTH OM ,
HOUSE SEWER CONNECTI NO TO P M.L.T. .L. }
PUBLIC SEWER ® $5,00
SEPTICTA K.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q 510.0° 1.NOHOUSE SEWER . V
PRIVATE DISPOSAL SYSTEM CD
TO CD 53,00 Tl1UNK PERMIT NO, RO PERMIT O
CONN ECT ADDITIONAL BLDG.ORr^
AF IpAVIT. w PEC IN R.NO. DATE [!'!
WORK TO HOUSE SEWER 53GO
OVERFLOW SEEPAGE PIT.DRAINFIELD
E%TN,.CESSPOOL.DRYWELL.MANHOLE Q^ 55.00
ALTER.REPAIR OR ABANDON HOUSE HWT, OR ST.WI° IN.
SEWER OR DISPOSAL SYSTEM 3,00 STATE ENCROACHMENT L
PERMIT NO.
INDUSTRIAL
WASTE APPROV AL
O RAS PERMIT E . A E V
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Jh
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIM8URSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%15TING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR5 SIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR 11��VI ` NEW HOUSE SEWER
OWNERS AGENT— f�_ L rf / CONNECT ADDITIONAL
9V ILOING OR WORK
A°DRE55 SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSE. AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRI ED RE51 NTI AL ROPERTY. ABANDON HOUSE SEW ER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM
"TEE_ SEEP.PITIBI ElCESSPOOLS ❑
^VALIDATION ROBERT WOOD
CK, M.o. CASH SUPERVISING MECHANICAL ENGINEER
�, Co0639-3 FEB 611 D 25.00- "