HomeMy Public PortalAbout9708 BROADWAY_Sewer__ 76AK41p APPLICATION FOR PERMIT ,
CEBOB a-ae COUNTY OF LOTkNGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION auamNG y
ADDRESS O L.
ttSs T A. LAMIE,GRIFFI , S.P't.ty -I ilei _
CASSAl'E D. GRIFFIN, Sup t of Building
NEAREST
FOR APPLICANT TO FILL INcRoss ST. e
LEGAL
DESCRIPTION LOT 10.Ar 11 OWNER
BLOCK TRACT Z�6p ADDRESS ;SC! G /
NO.OF BLDGS. 6/
SIZE OF LOT ,.�� NOW ONLOTLOT CITY / � TEL. NO.
BUELDI NGS /f, �/R�� DISTRICT N0.I GROUPBK MAP PG PRO SSED B
CONTRACTOR � `j � �T it
ADDRESS CONNECTION DATA
/ r
CITY / EL.N0. / [e STATION DEPTH
REGISTRATION NO. 6¢ ❑ COUNTY MANHOLE REFERENCE
No. DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 -� U:' TYPE OF CONNECTION LENGTH FROM
SEPTIC ANK,S/ORAENFlE PDT OR @ $3.00 Y. CURB P.L. M.L.TO P.L.PITS ...$��
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO - +� P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. 2 � JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK C HOUSE SEWER @ $I.00 TRUNK PERMIT NO. ROAD PERMIT N0. -"I5-O-,I
ALTER. REPAIR OR ABANDON HOUSE STJ.{�{HfRCffGRM ENT /
SEWER OR DISPOSAL SYSTEM @ $1.00 Ply _HO -'- � {� ��
INA@BTRIALL
WISi&MPROpAC- 1 3
A .
OWNERS PERMIT S 2 00 cDa4zGwa teeE— _-'22
AUTHORIZATION I TOTAL FEE _5' Q-0 1 REIMBURSEMENT FEE Hi
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- (/ b
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -F
SIGNED THIS DAY OF 19 NEW HOUSE SEWER ]'TI Ir -Fa/ 7�F•RN7/lA
OWNER OR CONNECT ADDITIONAL
" OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF pISCONNECT PLUG AND
ABANDON HOUSESAND
CALIFORNIA OR THAT 1 AM THE LEGAL NER A THE ABOVE
DESCRIBED RESIDENTIAL ERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE 3^ZI-EJ I+�LD�RMflN
®° �1VALIDATION ROBERT A. WOOD
CK M.0. CASH SUPERVISING MECHANICAL ENGINEER
UZO 7 8 1 7 b MAR 16 1 0 A 5 .0 0