HomeMy Public PortalAbout9639 BROADWAY_Sewer__ E8EA=°
CEEOe 6.68 APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING �� G
ADDRESS
CASSATT D.OHN A. GRIFFIN Supt of g]°Bdi°g /J
LOCALITY Lo .( P' f
NEAREST �i
FOR APPLICANT TO FILL IN CROSS ST. Y �/ p /
DESCRIPTION 'IE NO//i{,� rr 47 0 ,J J ✓ O
OWNER
MAIL
BLOCK TRACT/; �j D/V l_J ADDRESS
NO.OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT N0. GROUP MAP PR SE
BUILDINGS D BYBK PG
CONTRACTOR s f /Q >✓6 ��f / I P
ADDRESS/S— IPC / CONNECTION DATA
CITY TEL.NO. 2 - / STATION 0 DEPTH !
�l E MANHOLE REFERENCE'.7_
REGISTRATION N0. Z • Alz COUNTY
ND DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 3 TYPE OF CONNECTION LENGTH FROMSEPTIC TANK,
PITS AND/OR DRAINFIELDiT OR @ $3.00 CURB P.L. M.L.TO P.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 NO.
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO. Q
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSALABANDON SYSTEM HOUSE @ $100 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 47 [t Q REIMBURSEMENT FEE �/� cv
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 3rl
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. /91-N
SIGNED THIS DAY ¢F 19_ NEW HOUSE SEWER ( ./�
OWNER OR /�V/ CONNECT ADD[ IONAL
OWNERS AGENT BUILDING OR WORK
ADORES S SEPTIC TANK,SEEP.PIT(5)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
—
LICENSED
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AN STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I pM E LEGAL WNER 0 E ABOVE
DESCRIBED RESIDENTI L PERTY. ♦ BACKFILL
(SEPTIC
CESSPOOLS El ❑
SIGNATURE
OF PER
®> ALIDATION ROBERT A. WOOD
crc� H.°. GSR SUPERVISING MECHANICAL ENGINEER
J;1�p 6 7 4 9 FEB 19 1 0 A rJ.0 0