HomeMy Public PortalAbout9641 BROADWAY_Sewer__ 76A642 ° 63D APPLICATIO FOR PERM T
CE808
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
,.DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS /fes
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL �E�
DESCRIPTION LOT NO. y / S OWNER
MAIL
BLOCH ♦C 2/Z 1Z"V ���'� • ADD
NO. OF SLOGS. /J
S1ZE OF LOT NOW ON LOT CITY • ( TEL. NO.
USE OF
BUILDINGS DjI STRICT NO. GROUP MAP] PROCESSED BY1
CONTRACT $f L [P n .[ ✓
..DRESS ,[._ 7 CONNECTION DATA
STATION l DEPTH
CITY TO.
STATErlekUPPER
REGISTRATION NO. COUNTY MANHOLE REFERENCE
I
NO. DESCRIPTION OF WORK EE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER
CONNECTING TO T. CURB R.L. M.L.TO P.L.
PUBLIC SEWER
@ 55.00
SEPTIC TANK,SEEP.OE PIT OR P C NO O
CO.IMP.NO. JOB NO.
PITS ANO/OR ORAtNFIELD @ 510.09 U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. p'
PRIVATE DISPOSAL SYSTEM @ S3.00 0
CONNECT ADDITIONAL BLOB.OR AFFIDAVIT ql SERE IN5TR.NO.RECORD. DATE r
WORK TO HOUSE SEW E R @ S3.00 u
OVERFLOWSEEPAGE PIT,DRAINFIE L D W
E%TN..CESSPOOL,DRYWELL.MANHOLE 55.00
ALTER,REPAIR OR ABANDON HOUSE H D �yf
SEWER OR DISP05AL SYSTEM @ ".DO STATE ENCROACHMENT L
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $1 z 00
AUTHORIZATION TOTAL FEE ' CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. OATS INSPECTOR'5 SIGNATURE
SIGNED THIS DAY pF19
OWNER OR NEW HOUSE SEWER .
OWNERS AGENT B "
CONNECT ADDITIONAL
BUILDINGWORK
ADDRESS E
SEPTIC TANK
.SEER,IEL PITES) '
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION ANO/OR DftpINFIELD
AND STATE THgT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR A LTER, REPAIR,SEWER OR
LICENSED As REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM THE LEGAL OWNER OF ND INTEND TO DISCONNECT PLUG AND
RE51DE IN. TH q0 E DESCRIBED R ENTI P OPERTY. ABANDON HOUSE BEW ER
SIGNATURE BACKFILLSEPTIC TANKS ❑
OF PERMI ❑
CESSPOOLS
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
_riVG 2 2 SSP 2 :L 5.0 O '
CE808 D10-63
6A64 APPLICATION FgR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BD]LOHJG �.
JOHN A. LAMBIE. County Engineer AD DREss
WILLIAM A. JENSEN, Sup'1 of Building
LOCALITY
NEAREST
PLICANT TO FILL IN CRp55 ST.
J J j.
F777-
NO. O W� �( MAILCT AOORES5NO. OF BLDCD. //NOW ON LOT CITY p �TNO,
DISTRICT NO. GROUP MAP CESSED BY
y/�Hnx/ BK
CONTRACTOR /e I/ "l �`
ADDRESS R CONNECTION-/DATA
CITY V TEL. NO.`(IJ— /I- I- tr STATIONDEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY "
NO. OES� O ORK FEE TYPE OF CONNECT41 N LENGTH FROM•
HOl15E SEWER CONNECTING TO Y. Cu.. P.L. M.L.TO P.L. T'
PUBLIC SEWER $5.00 d
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR GRAINFIELD Q $10.00 CO.IMP. NO. JOB NO. V
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDGORAFFIDAVI RECOR O. INSTR.NO. DATE F
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD _ W
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $SOO 10,
pLitcwBR ABANDON HOUSE HWY. OR YT.WIDE ING h
Ll SEWER do
STATE NCROACHMENT
PERMITPERMIT NO.
ING VBTRIAL
WASTE APPROVAL
OWNERS PERMIT 5 2 CHARGES
1 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF I9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTI
I HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLICATION AN./O0.pRAICTANKSNFIELEEP.PIT(S)
AND/ ELO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
CE
LINSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AN
p �AA[� —/
RESIDE IN. THE ABOV£ DESCRIB RESIDENTIAL PROPERTY. ABANDON HODS ESEWER p7QJIJ �/ Il� '1 .,
SIGNATURE I
OF PERMITTE ( BACKFILL SEPTIC TANKS ❑ (
5EEP.PIT IB) El CESSPOOLS
❑
VALIDATI ROBERT A. WOOD
UPERVISING MECHANICAL ENGINEER
CK. M,0. CPSH
D J.GO
:l'u� 4 1 2 4" J1,112929 1 C �