HomeMy Public PortalAbout9626 1/2 BROADWAY_Sewer__ 5&R-6311 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles IU DING ! y�y T. D/ � /�
.JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS / (O G /-tA�'
® CASSATT D. GRIFFIN. SOFT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN p NEAREST
LEGAL OWNER
DESCRIPTION LOT NO. Q O
�'1/.�dt�er AIL
BLOCK TRACT ADDRESS
I/a I JNO. OF BLDGS' CITY TEL. NO.
SIZE OF LOT X�'/f'�NOW ON LOi
USE OF DISTRICT NO. GROUP MAP
BUILDINGS c�-s•. . i T B PG
CONTRACTOR �� 104ADDRESS ._J �i-
,y/ CONNECTION DATA
to 14,
CITY ���,. rl"��'`� r� STA ION q fG EPTH !
TEL. N0. �'S� 7
MANN RF ER ACE UPPER
REGISTRATION N0. IL-T Q'COUNTY s Q LOWER
No. DESCRIPTION OF WORK FEE 8-1'
L OF CONNECTIO LENG , FROM 1
/
HOUSE SEWER CONNECTING TO �/ y- V CURB P.L.J M.L. O P.L.
Y/ PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD P. C. NO.
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $2.00JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM (a1 $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
J CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
-4 WORK TO HOUSE SEWER Q $I.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ 5 1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS ' DATE INSPgCTOR'SSIGN JURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER S� i
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT Nv
SEPTIC TANK,SEEP,PIT(S)
ADDRESS ANO/Oft GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ECT PLUG AND
ONN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
ON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIO ROBERT A. WOOD.CHIEF PLBG. INSPECTOR
CK, M.O. CASH
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