HomeMy Public PortalAbout9653 BROADWAY_Sewer__ `6A6420 2
T6A692D APPLICAl ION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL U
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION poo css l' ff/� !
JOHN A, LAMBIE, County Engineer /
WILLIAM A. JENSEN. Supt of Building�_j r/7 AC r
LOCALITY
-- ' ---- - - NEAREST
FOR APPLICA T T FILL RV CREIS5 5T.
G �n
I O OWNER
MAIL
B CT
ADDRESS /
O. OF BLOCS. r� IIIOA
SIZE OF LOT OW ON LOT CITY C TEL. NO. R� VV
USE OF
BUILDINGSp DISTRICT�/(NCO. GRO/UP BK MAP PC�f PROCESSED BY
CONTRACTOR j/L' �1��' 4'+ `� .S C�IJ JJ \J `�\ ���•,X�� /
ADDgess ro _ — r` CONNECTION DATA
CITY y TEL. N Z70-0 STATION DEPTH
1��+ STATE UPPER
REGISTRATION NO. LJ COUNTY MANHOLE RERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CON CTION NGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L.. M.L.TO P.L.
PUBLIC SEWER @ $5.00 _
SEPTIC TANK,,SEEPAGE PIT OR .C.NO.
FITS ANO/OR DRAINFIELD @ $10.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE TEM @ $300
CONNECT ADDITIONAL
BLDG.OR AFFIDAVIT WAIVE[ EASE RECCR INSTR. NO. GATE jj�[$}Q=L=;�JI,i
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL,DRYWELL.MANH O LE@ $5.00
Ak46F�AGPAJF�BTABANDON HOUSE ea.J HWY. OR ST.WIDENIN
DISPOSAL SYSTEM @ $3.00 STATE ENCfl OACHM T
PERMIT NO.
INDUSTRIAL
WASTE APPRO L
CHARGES
OWNER'S PERMIT 3 2 00
AUTHORIZATION I TOTAL FEEE^ CONNECTION CHARGE FEE
L/
I HAVE AT THIS PATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
ON-�
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
— / BUILDING OR WORK
ADORE55 ( SEPTIC TANK,SEE P,FIT(5)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
L IC ENSEO AS REQUIRED BY LOS ANGLES COUNTY AND STAT OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWNER OF, ANO INT O TO OISCONN ECT PLUG AND
RESIDE IN. THE AB V O CRISCO IDENTIAL PROPERT
' ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEEBACKFILL SEPTIC TANKS
4 p
SEEP,PIT(.) [I <ESSPOOL'Y R/D
,VALIDATION ROSERT 'A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
UAo 9 1 4 3 AN 7 1 0 D 5.0 G- s