HomeMy Public PortalAbout9651 BROADWAY_Sewer__ 10
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APPLICATION FOR PERMIT
E008
COUNTY OF LOS ANGELES SEWER-SEWAGE"DISPOSAL•-`1
DEPARTMENT OF COUNTY ENGINEER • w -
BUILDING AND SAFETY DMSION BUILDIN'c ll
JOHN A, LAMBIE, County Eagineer AD OR ESS dYj 'YG? ✓
CAC D. GRIFFIN. Sup t.oI 8uildivg I
LOCALITY
NEAREST
FOR APPLICANT TO FILL11 - CROSS ST.
LEGAL Y • U I 1'
DESCRIPTION LOT NO.
BLOCK TRACT OWNER OWNER fy��
MAIL
ADDRESS
NO.OF BLDGS, _
SIZE OF LOT NOW ON LOT Z CITY TEL.'N0.
USE OF
BUILD,NGS DISTRICT/NO. GROUP MAP
CONTRAC R• L-t J5BK. PG
ADDRESS S`S T CONNECCT`ION DATA
CITY 5 TEL. N . STATION DEPTH
STATE MAN
REGISTRATION N0. HOLE REFERENC® COUNTY - LOWER
NO'1 TIO OF WORK FE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAIN F,ELO @ $B4O0 Y. CURB P,i. M.L.TO P.L4
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN„CESSPOOL.DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO
/ P, C. NO.
PRIVATE D15POSAL SYSTEM @ $1.00 CO.IMP. NO. 1 2-74 JOB NO.
CONNECT OUSE SEWS BLDG.OR /4—
ALTER,
/�
WORK TOHOUSESEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIft9R ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
_.INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERSPERMIT $ T. 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE _ REIMBURSEMENT FEE
I HAVE AT THIS DATE A-CONTRACT WITH THE HEREIN NAMED CONS
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE, INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _ _ _ _
SIGNED THIS AY OF pg NEW HOUSE SEWER
OWNER OR � - - - - -- CONNECT ADDITIONAL - — - -” --- _ -�
OWNERS AGENT BUILDING OR WORK
ADORES$ - - - SEPTIC-TANK,SEEP,-PIT(S)- - - - - --
AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY >. CESSPOOL 171DRYWELL El - '
WITH ALL COUNTY -ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR,SEWER OR -
1 HEREBY CERTIFY THAT'I AM PROPERLY REGISTERED ANO/OR -SEWAGE.DISPOSAL -.--
LICENSEO AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
C ORNIA OR THAT. 1 AM THE LEGAL OWNER OF T E ABOVE. ABANDON HOUSE SEW ER - _ _-
SCR ED RESIDENT L PROPER} BACKFILL SEPTIC TANKS ❑
I ,`/ SEEP.PITIS) (]CESSPOOLS ❑
P
VALIDATI ROBERT A. WOOD
CK. x.oAsx SUPERVISING MECHANICAL ENGINEER
_ _ 11U 3 3 9 DEC' 10 A 5 .b 0