HomeMy Public PortalAbout9557 BROADWAY_Sewer__ CERDB 3-64 � �
76A64
20 APPLICATION FOR P RMI,
COUNTY OF LOS ANGELES E II
DEPARTMENT OF COUNTY ENGINEER SEWER—SE AGE DISPOSAL IIIJJJ
BUILDING AND SAFETY DIVISION BUILDING �.�
JOHN A. LAMBIE, County Engines[ ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREvT
FOR APPLICANT TO FILL IN `ROSS BT
LEGAL �j�
DE9CRIPT ION LOT NO. �,K OWNER
MAIL l
BLOCK �j[/ ADDRESS
NO. OF BL OGS.
SIZE OF LOT NOW ON LOT CITY �• TEL .NO.
USE OF DISTRICT NO. GROUP MAP PROCE O BY
BUILDINGS
Q _/ BK PG
CONTRACTOR �J0
ADDRESS CONNECTION DTA
CITY T STATION _ DEPTH
�J STATE MANHOLE REFERENCE 1y-/
REGISTRATION NO. PB COUNTY / /V' LOWER
NO. 0ESCRI PTION OF WORK FE TYPE OFC CTI N LENGTH.FR %
HOUSE.SEWER CONNECTING TO Y. CUR P.L. M.L.TO P.L.
PUBLIC BOWER a $5.00
SEPTIC TANK,SEEPAGE PIT OR ' '12 i P.C.NO. }
PITS AND/OR SEEPAGE
a $10.00 CO.IMP. NO. 6 JOB NO. D.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N O
PRIVATE DISPOSAL SYSTEM ® S3.00
CONNECT ADDITIONALBLDG.OR AFFIDAVIT WMY[II [[.[[Y[MT RECORD,INBTR.NO. DATE N.
WORK TO HOUSE SEWER ® 13.00 OT's O
OVERFLOW SEEPAGE PIT,DRAINFIELD N
EXTN.,CESSPOOL,DRYWELL.MANHOLE 0 $8.00 U
ALTER,REPAIR OR ABANDON HOUSE OR ST.WIDENING OL
SEWER OR DISPO,SAL 8TEM ® $3.00 STATE ENCROACHMENT A)
PERMIT NO. Z_
INDUSTRIAL
WASTE APPROVAL
CHARGES
R'S PER* s 2 .00
AUTHORIZATION TOTAL FEE I 4
._0 CONNECTION CHARGE FEC
'1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED %ISTINO WEL NO
TO THE PUBLIC'SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL ,
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S) •' • '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND 4GREE TO COMPLY
WITH ALL COUNTY ORDINANCES ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
L
ICENSED POUTED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
ALIFOR O THAT AM THE LEG4L O ER OF. AND INTEND TO DISCONNECTPLUG ANO
ESID IN, E ABOVE DE���/py� BED R NTIIAAL�PROPE ABANDON HOU.E SEWER
IG AT � V BACKFILL SEPTIC TANKS ❑
O 6EEP.PITISI ❑ CESSPOOLS ❑
VALIDATION„�'`�1' ROBERT A. WOOD
CK. M.0. CA6H
�Q�` )SUPERVISING MECHANICAL ENGINEER
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