HomeMy Public PortalAbout9556 BROADWAY_Sewer__ TAAB"° APPLICATION FOR PERMIT
ceeoee.ss COUNTY OF LOS ANGELES
I, SEWER—SEWAGE DISPOSAL
DEPARTMENT of couNTr ENGINEER
•BUILDING AND SAFETY DIVISION BUILDING {, —
ADDRESS ,C�✓
JOHN A. LAMBIE. County Eagiveer
CASSATT D. GRIFFIN, Sup'Yo/Building LOCALITY
., _ .. NEAREST
FOR APPLICANT TO FILL CR OSS ST.
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C ;5 CT OWNER - D'
TRAMAIL
ADDRESS-
NO.
DDRESS NO. OF BLDGS. -
SIZE OF LOT p NOW ON LOT CITY TEL.•NO,
USE OF
BUILDINGS / DISTRICT N0. GROUP MAP PROCESSED BY n
CONTRACTOR
ADDRESS j y� jam-- f CONNECTION DATA
CITY EL. NO. STATION O DEPTH
/ .s STATE a MANHOLE REFERENCE -
/ R
REGISTRATION N0. / (O a- � COUNTY
NO. I DESCRIPTION OF WORK FEE Ow
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION-. LENGTHFROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB .L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EKTN-CESSPOOL.DRYWELL,MAN HOLE @ $2.00
ROUSE SEWER CONNECTING TO P.C,N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO./� _ JOB N1.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO- ROAD PERMIT N0. aOs
WORK TO HOUSE SEWER R $1.00
ALTER,.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 - PERMIT NO.
.,INDUSTRIAL
.WASTE APPROVAL
CHARGES
OWNER'S. PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION FTOTIM FEE &T REIMBURSEMENT FEE /A 1Ln A -O,
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS - 0/TEYT/CIN3Pv6GTO R'S SIGNATURE
HAVE
TO CONNECT T E ABOVE DESCRIBED EXISTING DWELLING.
TO THE ToCONNECT
_ SIGNED THIS B AY OF Iyy� NEW HOUSE SEWER (J LX'7l
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT •BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRES AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
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 ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI P PERTY. BACKFILL SEPTIC TANKS❑
s SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE
®r _VALIDATION ROBERTA.WOOD
crc.
M.o. CASH SUPERVISING MECHANICAL ENGINEER
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