HomeMy Public PortalAbout9723 BROADWAY_Sewer__ R6D
5 IN -
APPLICATION FOOD PERMIT
INR-663
OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer - - - - - - -
County of Los Angeles BUILDING [17� 0 ��
WM.J. FOX, COUNTY ENGINEER ADDRESS 4
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY � C
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL ^
DESCRIPTION LOT N0. DOWNER n 'G
BLOCK TRACT MAIL
ADDRESS / / Z Q W
SIZE OF LOT YT NO N LOT CITY lq&,y}� TEL. NO.
USE OF '-I/f+ -'
_BUILDINGS 14-ik4 L/A/f`s DISTRICT NO. GROUP MAP
(^�If� � `� SK r PG
CONTRACTOR luAN yl1 ^ �� A AT 2;$41, �
ADDRESS G / y,6 CONNECTION DATA ?
CITY TEL. NO. ' 77 / g STATION ®'/ DEPTH
El
REGISTRATION NO. //6 / v c D• COUTNTY MANHOLE REFERENCE /nr-709 ' LOQ
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB P.L. M . TO P.L. v
PUBLIC SEWER Q B 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _ �/E�[Y, S
CONNECT HOUSE SEW BLDG. OR CO. IMP. NO. / PjOp3CJ. 3 • V _5
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT 14 0. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S $ 1 OD
AUTHORIZATION TOTAL FEE SO REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPIECTOR'S SIGNATURE
TO THE PUBLICS VE'g(,
SIGNED THIS ^�+DAY 0F�192 o NEW HOUSE SEWER I �r�
OWNER OR �A^ CONNECT ADDITIONAL 1
OWNERS AGENT ' '^ , 'F/ BUILDING OR WORK
�/ I � SEPTIC TANK. SEEP, PIT(S)
ADDRESS > _ I AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION . CESSPOOL D DRYWELL D
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL
N�PROPERTY.
I //� ��� /// BACKFILL SEPTIC TANKS
SIGNATURE C1I��' �A/T/Wl'1 ��r19WflP'S SEEP. PIT(S) CESSPOOLS D
OF PERMITTEE
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R.A. WOOD, CHIEF PLBG. INSPECTOR
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