HomeMy Public PortalAbout9657 BROADWAY_Sewer__ CEBOBB-B2
Tsge AZD APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADD REss
WILLIAM A. JENSEN. Sup't of Building
LOCALITY '
NEAREST '
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL `y
OESC RIPTIDN LOT N0 �02 C/G .2G.1 OWNER
MAIL
��
BLOCK TRACTl ADDRESS
NO. OF BLDGS. S✓• �y
SIZE OF LOT NOW ON LOT r CITY - • IEL. NO.
VSE OF / BY
BUILDINGS /p DISTRICT N6.1 GROUPI MAP PROCESSED
CONTRACTOR A /� 8H_ P
gppREss N �J CO{/A_NECTION DATA
NO. STATION Iv DEPTH
STATE
REGISTRATION NO. .0a CMANHOLE REFERENCE
OUNTY (. LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CO TIO _ LENGTH FROI �/
HOUSE SEWER CONNECTING TO RfA� Y. RB M.L.TO E.L.
P.C.NO.
d
PUBLIC SEWER @ S5.00 O
SEPTIC TANK SEEPAGE PIT OR
PITS ANO/OR GRAINFIELD A SIO.00 CO.IMP.NO.
NO U BE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, y O
PRIVATE DISPOSAL SYSTEM ".0 (/ `
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT EASII.E.r RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ 53.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN„CEESPOOL.DRYWELL.MANHOLE@ SS.OQ - y
ALTER.REPAIR OR ABANDON MOUSE HWY.ORST.WIDENING Z_
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
AUTHORIZATION TOTAL FEE on
CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AME. CO.- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIST IG DWELLING
TO THE PUBLIC SEWER. APPROVALSDATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF-19—
OWNER
F19OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
- BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(E)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/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 ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REQUIRED BY 'LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE L G ER OF. AND INTEND TO DISCONNECT PLUG ANO
RESIDE IN, THE AS DEBCRIB p SID IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SCEP.PITISI ❑ CESSPOOLS ❑
OVALIDATION ROBERT A. WOOD
cK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
JD 2 3 7 3Q fVkR 2 2 1 0 D 7.010 `,