HomeMy Public PortalAbout9659 BROADWAY_Sewer__ EA.-
E800 3.62 APPLICATION FOR PERMIT '✓
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIIDING
TORN A. LAMBIE, County Engineer ADDREss
WILLIAM A. IENSEN, Sup't of Building L
LOCALITY r
NEAREST
FOR APPLICANT TO FILL IN CROSS PT.
DES CR`AL IPTI ON LOT NO.�f l Q J '1�(/ _< \ OWNER 1" O
MAIL
BLOCK TRACT � �y_I,'a I ADDREGS
NO. OF
SIZE OF LOT NOW ON LOT / CITY A TEL. NO.
USE OF
DUILDINGS H DISTRICT NO. GNOUPM=P PROCESSED
BY
!1� BK
CONTRACTOR EIS �NY1 / PG
7 App�ge�s�+lL'��QA
CONNECTION ECTION DATA
CIT TEL rf) @j �(TEL_ NA � Z� 5 A ION DEPTHEl STATE
REGISTRATION) NO. // ' [ICOUNTY MANHOLE REFERENCE , LOWER
NO. I DESCRIPTION OF WORK FEE T E OF C N N LENGTH F M
/ HOUSE SEWER CONNECTING TO Y. P. M.L.TO P. a
PUBLIC SEWER Q $5.00
PEPTIC TANK.SEEPAGE PIT OR
PCOI.E. NO.
ITS qNp/OR GRAINFIELD 810.00
. JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O �'
PRIVATE DISPOSAL SYSTEM $3.00
CONNE CT ADDITIONAL SLOG.OR AFFIDAVIT AIV ASEMi RECORD. INSTR.NO. DATE
WORKT O HOUSE SEWERS3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWEL_.MANHOLE $5.00 VJ
ALTER,REPAIR OR AB ANDON HOUSE HWY.OR ST,WIDENING Z
SEWER OR DISPOSAL SYSTEM 33.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WA EAPPROV L
OWNERS I PERMIT 5 z DoRGEs iI
AUTHORIZATION TOTAL FEE 10
0 ON NECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'SSINA URE
SIGNED THIS DAY O 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNIETApDIT10NAL A �
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SE151
ANO�OR DRAINFIELD
EL°
AND STATE THAT THE ABOVE IE CORRECT AND AGREE COMPLY
WITH ALL COUNTY OROINA NCEP AND STATE LAWS REGULATING
PLUMBING AND'SEW ERP. _ CESSPOOL ❑ DRYW ELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A THE LEGA R OF. AND INTEND TO LS'. PLUG AND
RESIDE IN, THE ABO��ES CRUDE S EN PROP�E R�,T.SY/./ gBAN DON HOUSE SEWER
SIGNATURE �� BACKFILL SEPT IC TANKS ❑
OF PERMITTEE SEEP,PITISI ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK. M.O. CASH SUPERVISING MECHANICAL ENGINEER '
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CEBOB 3-S2 APPLICATION FOR PERMIT j IIJJ
COUNTY OF LOS ANGELES SEWER—S AG DISPOSAL
DEPARTMENT OF COUNTY ENGINEER �•_
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. TENS EN. Sup't o1 Building
CLOCA
NEAREST
FOR APPLICANT TO FILL IN `ROBS ST,
LEGAL / q �j
DED OPTION LOT NO, 'Y Q.S q � OWNER O �IJ
—J-V-- MAIL
BLOCI( TRS/'M/ A OILS n .1L /e A ADDRESS
NO. OF BLOTS.
SIZE OF LOT NOW ON LOT / CITY TEL, NO,
USE OF
BUILDINGS DISTRICT NO. GRO MAP PROCE5SED BY
CONTRACTOR/^f ✓� t/ y �K 7/-3
ABEREs /!(�!/?i d/ CO✓✓NNECTION DATA
CITYL NO. 3T N ' DEPTH
REGISTgATION NO. / %D��1 El COUNTY MANHOLE DEFERENCE 1 LOWER
NO, DESCRIPTION OF WORK FEE EOF N ON LENGTHF M
HOVSE BEWER CONNECTING TO Y. .L. M.L.TO P. O
PUBLIC SEW ER $8.00
SEPTIC TANK,SEEPAGE PIT OR P.0 NO. V
PITS AND/OR DRAINFIELD @ $10.00 CO.U.P. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO. p,Qq/] O
PRIVATE DISPOSAL SYSTEM @ $300 y' 0
CONN ECT ADUI T IONAL BLOC.OR AFFIDAVIT WAIVERRECORD.INSTR.NO.
EASEMENT DATE
WORK TO HOUSE SEWER CR $8.00
OVERFLOW SEEPAGE PIT,GRAINFIELD y
EXTN.,CESSPOOL.DRYWELL:MANHOLE Q 35,00 9
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING L_
SEWE RDISPCXA Y EM $8.00 STATE ENC.-ACHMENT
PERMIT NO.
INDUSTRIAL
WASJAIRAPPROVAL
RTES.) j
OWNERS PERMIT s
AUTHORIZATION TOTAL FEE ry 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, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNEROR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR BRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEEERY
CERTIFY THA I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRE B LOB ANGLES COUNT AND $TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM HE LEGAL OW F, A D INTEND TO
RE51DE N. THE AB E OE CRIBED RE51D T L P qTY. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE_ BACKFILL SEPTIC TANKS ❑
BEEP.PIT(3) ❑ CESSPOOLS ❑
QVALIDATION ROBERT A. WOOD
cK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
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