HomeMy Public PortalAbout9545 BROADWAY_Sewer__ CE60610-63 - .APPLICATION FOR PER �
T6A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADo HESS
WILLIAM A. IENBEN, Svp'1 0l Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
IEGgL
DESCRIPTION LOT NO. -.Q OWNER.
MAIL �yJ
BLOCK TRA- / �iC ADDRESS
NO. OF BLGGS.
SI2E OF LOT NOW ON LOT CITY L. NO.
USE OF DISTRICT NO. GROUP MAP PROCESS BT
BUILDING$
BK PG
CONTRACTOR �-1 IC ,�L_ (/
ADDRESS �. Q4 `/ / CONNECTION DATA Y' '
CITY TEL. NO. O O STATION _l JI DEPTH L+
TATEC./ PPER
REGISTRATION NO, D COUNTY M4NHOLE REFERENC
NO. DESCRIPTION OF WORK FEE TYPE OF CO C LENGTHF.OM
HOUSE SEWER CONNECTING TO V. URB P.l M.L.TO :L �
PUBLICSEWER 35.00
P.C.NO. O
SEPTIC TANK.SEEPAGE PIT OR COIMP. -O-1-'1 JOB NO.
.
PITS AND/OR DRAINFIELD SIO.00U
HO U SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @D $3.00 /N
CONNECT ADDITIONAL BLDG.OR I gFF1D MY SEX[NT RECORD.INSTR.NO. DATE VU
WORK TO HOUSE SEWER ® 33.00
OVERFLOW SEEPAGE PIT.GRAINFIELD I W
E%TN.,CESSPOOL.ORYW ELL,.NHOLE� f5,00 d
AL '^' ^^^ABANDON HOUSE .vY HWY. OR ST.WIDENING
SEWER ORWYJ}OYAL'SYSTEM ® 33.00 l] STATE ENCROACHMENT
zi L PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 'z 'o
AUTHORIZATION TOTAL FEE CONNECT CNAgGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%ISTIN WELLING APPROVALS
TO THE PUBLIC SE DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY F D
OWNER OR NEW HOUSE SEWER
OWNER5 ADEN
CONNECT ADDITIOAL
ADDRESS
BUILDING OR WORK
SEPTIC TANK,SEEP.PIT 151
HEREBY ACKNOWLEDGE HAVE DEAD THIS APPLICATION qNp/OR GRAINFIELD
G AB
ANSTATE THAT THE OVEE IS CORRECT
AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S AND STATETE TO LAWS REE GULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL 9QNER OF. AND INTEND TO DISCONNECT PLUAND
E
RESIDE IN, THE ABOVE DSCRI D RE NTIAL PROPERTY.
ABANDON HOUSE SG EWER o
SIGNATUREln
BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(SI ❑ CESSPOOLS ❑ _
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
0 7 6 91.2 , o D 1 0.00-
.