HomeMy Public PortalAbout9705 BROADWAY_Sewer__ CE90910-63 APPLICATION FOR+PERMIT 9�ocS
]6A692D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION .."DUN. O
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
O� LI T- LL Rp55 5T.
GAL
DESE
CRIPTION LOT O. ' f 'a. OWNER
MAIL
BLOCK TRAC 11/ �.� C ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT I CITY TEL. NO.
USE OF
DISTRICT NO. GROUP MAP PROCESSED BY
BUILD I NOS
<,� BK PG
CONTRACTOR f /1
ADDRESS CONNECTION DATA
CITY TEL. N .TION DEPTH
UPPER
REGISTRATION NO.
piL-0�� COUNTY S TATE MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE CON E N LENGTH FROM
MOUSE SEWER CONNECTING TO Y, Y P.L. M,L.TO P.L. a
PUBLIC SEWER @ 45.00 f,,C.NO. O
SEPTIC TANK.SEEPAGE PIT OR CO.I.P. NO. JOB NO.
PITS AND/OR GRAINFIELD $10.00 V
PRIVATE DISPOSHO USE SEWER ANNECTING L SYSTEM TO $3.00 TRUNK PERMIT NO. ROAD PERMIT NO, 1 lC�
CONNECT ADDITIONAL BLDG,OR AFFI USII.E.T RECORD.INSTR.NO. DATE F
WORK TO HOUSE SEWER ® $3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD W
EXTN.,CESEPOOL,ORYWELL.MANHOLE@ $5.00 d
ALTER, REPAIR OR ABANDON HOUSEHWY,OR ST.WIDENING qy
SEWER ON DISPOSAL SYSTEM $3,00 STATE ENCROACHMENT L
PERMIT NO.
INDUSTRIAL
WASTEAPPROVAL
OWNERS PEAMIT S z 00 CHARGES
1_pNNE111pN CHARGE FEE
AUTIiORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBEO EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE I INSPECTOR55IGNATURE
SIGNED THIS DA OEJ 19_
10W NER OR NEW HOUSE SEWER
OWNERS AG `IT ���J / Y
VVVVVV CONNECT ADDITIONAL
f BUILDING OR WORK
ADDRESS --
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPT ICTANKP,PIT(S)
ND/OR GRAINFINFIELD
AN STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ DAYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A /.B ALTER, REPAIR,SEWER OR
LICENSED AS RCOUIREO BY ANGLES COUNTY ANO ST E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I q LEGAL OWNER OF, ANO IN ND TO
RESIDE IN, THE ABOV ES RIBED RESIDEN P E DISCONNECT SESLUG AND
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE_ BACKFILL SEPTIC TANKS ❑
SEEP.PIT f51 ❑ CESSPOOLS ❑
VALIDATIONA. ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. C.BH
L, -;C) 4 8 3 1- JU124 1 0 0 7.00"'
� Y
CEBOB 10-63 APPLICATION FOR PE MIT -
76A6420
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILGING O
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building /
LOCALITY C _
NEAREST
GAL
FOR APPLICAN TO F LMDS$ 5T. - 1
°ESCERIPTION LOT NO. � O IN �� OWNER _
g _ MAIL
BLOCK TRACT rVY A..PESS
NO. OF BLOC
512E OF LOT NOW ON LOT CITY TEL, NO,
USE OF DISTRICT NO. GROUP BK PG MAP PROCESSED BY
BUILDING$
CONTRAC
ADDRESS / V CONNECTION DATA
CITY, TE ® ¢ `' TION DEPTH
ATE • UPPER
g EGISTRATION NO. � [] COUNTY MANHOLE REFERENCELOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECT LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C B .L. M.L TO P., }
PU BLIC SEWER $5.00
P.C.NO. a
SEPTIC TA N K,SEEPAGE PIT Oq O
PITS ANO/OR DRAINFIELO $10.00 CO.IMP. NO. JOB PER
HOTS E SEWER CONNECTING TO O. V
TRUNK PERMIT NO, ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 IX
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT IMIIL.IxT RECORD.INSTR,NO. OAT. O
WORK TO HOUSE SEWER $3.00 V
OVERFLOW SEEPAGE PIT,GRAINFIELD
W
EXTN_CESSPOOL.ORYWELL.MA NHOLE g3.00 D_
HWY.OR ST.WIDENING
ALTER,REPAIR O NOON HOUSE fII
SEWER pq DI SP SYSTEM 53.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT I
CHARGES
AUTHORIZATION I TOTAL FEE ON NECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DMAINFIELO
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
HEREBY CERTIFY THAT AM PROPERLY REGISTERED ANO/OR q LTER.REPAIR.SEWER OR
LICENSED AS REQUIRED LOS ANGLES COUNTY AND' TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH T AM HE LEGAL OW q OF NO NTENO TO
RESIDE IN. THE E SCRIBED RESI TIAL POP RTY. DISCONNECT PLUG ANO
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANK$ ❑
OF "FMITT
5EEP,PIT ISI [TICE
CESSPOOLS q
VA N"-,, ROBERT A. WOOD
/ SUPERVISING MECHANICAL ENGINEER
CK. CASHASH
Ljt;C4 3 3 0-� JAN24 1 1 D 2 5.00