HomeMy Public PortalAbout9702 BROADWAY_Sewer__ � 1
�Eaoa'a
s, APPLICATION FOR P IRMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION SION BUILDING
ADDRESSJOHN Lt o1W
SBAT A. L GRIFFIN,
County f Builder
GASSATT D. GRIFFIN. Hup't of Building LOCALITY
TO J/��
FOR APPLICANT FILL IN
CROSS T. ,/ley Yr Q
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACTS MAIL
ADDRESS
NO.OF BLDGS. /
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF V'
BUILDINGS P _ 4,1 LI DISTRICT N0. GROUP MAP PRO $SED B
CONTRACTOR -r I
j�
J O .
ADDRESS / CONNECTION DATA
CITY (Fj TEL. N0. CJ STATION DEPTH O
REGISTRATION NO.
(J Z� COUNTY MANHOLE REFERENCE PER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO it
PUBLIC SEWER @ $3.00 o
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM / r
PITS AND/OR DRAINFIELD Q $3.00 Y. CURB P.L. j M.L. TO P.L. iw
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXT N.,CESSPOO L.DRYW E L L.MAN H O LE @ $2.00
HOUSE SEWER CONNECTING TO P.C. 0.
PRIVATE DISPOSAL SYSTEM ($ $1.00 CO.IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR - TRUNK PERMIT NO. ROAD PERM�.
WORK TO HOUSE SEWER @ $1.00
ALTER ORDDISPOSAL SYSTEM HOUSE $1 OO STATE EH OACHMENT_
PERMIT NO.
INDUSTRIAL
WASTE APPROVAI
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE D REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
^/ 1♦` �, A � :vo6G
- SIGNED TH Y ) J NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PITS)
ADD ESS, pN0/OR DRAINFIELD
I HEREBY ACKNO LED E THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY RE0ITERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
t DESCRIBED R AL PROPERTY. '+ BACKFILL SEPTIC TANKS❑
SIGNATURE - SEEP. PIT(S) ❑ CESSPOOLS
OF.PERMIT TE /t
®. ALIDATION ROBERT A.WOOD
pp, y,p, pASx SUPERVISING MECHANICAL ENGINEER
I.