HomeMy Public PortalAbout9635 BROADWAY_Sewer__ Tepe<xD
ceeoe 11-so APPLICATION FOR PERMIT rSP11FURTEs7-tk&, I
COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL JL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION AUDDRE S
ADDRESS
OHN A. I.Ahffi]E, County Fmgfneor
C SSATT D. GRIFFIN, Sup t of Building LOCALITY 1 / 1
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.LEGAL
DESCRIPTION CNO.9I'.?'� F/ O OWNER
BLOCK TRACT MAIL
n./I MAIL
(ir' r ADDRESS
N0.OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT N0. GROUP BK MAP PG PROCESSED
CONTRACTOR �/QZ (�. �� I Z
ADDRESS y�^^ ��' CONNECTION DATA
CITY TE L.NO. d._ ,/� �� ION DEPTH
❑ STATE MANHOLE REFERENCE p
REGISTRATION NO. ❑ COUNTY a
NO. I DESCRIPTION OF WORK FEEHOU ,gyp O
PUBLISEWER
WR
E EECONNECTING TO @ $9.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $5.00 Y. CURB P.L. M .TO L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO _ P.C.NO.
PRIVATE DISPOSAL SYSTEM @ 51.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00
SEWER OF DISPOSAL STSTOEM HOUSE @ 5100 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REI MBURSEMENT FEE, HAVE AT TH �✓�ry
TRACTOR TO CIONNECT T EO NTRACT ABOVE DESCRIBED EXISTIWITH THEfNGAMED DWELLING APPROVALS /J DATE C INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �j ,{/n�
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER -Z^ ,(ITY;YY
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ��L"rC� BUI LDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑ I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SEWER OR
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGNELT PLUG AND
EM
LICENSED AS REQUIRED BY LOS NGELES COUNTY AND STATE OF DISCONABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM T LEGAL OWNER THE ABOVE
DESCRIBED RESIDENTIAL PRO TY. BAC FI LL SEPTIC TANKS E]SIGNATURE �� .1 SE PIT(S) ❑ CESSPOOLS �.
OF PERMITT ✓�/�
®CATION ROBERT A. WOOD
o. GSH SUPERVISING MECHANICAL ENGINEER
- }&6745 FEB 19 0 A 5.00
T'A'°=°
CE9ee 889 APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUR,DING AND SAFETY DMSION BUILDING O
TORN A. LAN®IE, County. Engm�e� ADDRESS F
CASSATT D. GRIFFIN, Sup t of Building LOCALITY 617
N REST
CROSS ST, r ! G
FOR AP
�CP
j/LIC
//A
�N
JT TO FILL IN ✓
DESCRIPTION DAL rT NW I iC L OWNER
BLOCK TRACTMAIL
/ ADDRESS
NO.OF BL GS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF p
eUI LOIN GS C- DISTRICT NO. GROUP MAP P ESSED B '
_�ys� BK PG
CONTRACTOR 'Qa /JIP'vp J / I r
ADDRESS C 7 ef A C G/4141 /� CONNECTION DATA
CITY moi+ TEL.N0. 6'; /9 ION ZlZj2 DEPTH /
[f'-STATE MANHOLE REFERENCE DPP
REGISTRATION NO. / V (��/ ` ❑ COUNTY
ND. I DESCRIPTION O WORK FEE 'J0^ C V,l Dry
HOUSE SEWER CONNECTING TO 3 .511 T F P!G '^ eA*
PUBLIC SEWER @ $5.00 TYPE OF CONNECTION LENGTH FROM
PEPTIC TANK.SEEPAGE TS AND/OR DRAINFIELD OR @ $3.00 Y. CURB P.L. M.L.TO .L. /
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. JOB N0.
CONNECT BLDG.OR
WORK C HOUSE SEWER
R @ $1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SeEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA OF 19_ CNEWON HOUSE ADDITIONAL OWNER OR CONNECT ADDITIONAL
SEWER
OWNERS AGENT BU iLDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
ANO/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
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
DISPOSAL
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEGAL OW OF THE ABOVE
DESCRIBED RESIDENTIA ROPERTY. f BACKFILL SEPTIC TANKS CI1 C� ,PIT(S) ❑ CESSPOO ❑
SIGNATURE
OF PER E
®" VALIDATION ROBERT A. WOOD
crc.
M.Q. CASH SUPERVISING MECHANICAL ENGINEER
! J�6746S FEB 1911 A 25.00 a
�1YGC�12�Y✓