HomeMy Public PortalAbout9728 BROADWAY_Sewer__ 76A"ED APPLICATION FOR PERMIT
. S&E-6.3 12.54
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
' Dep=tment of County Engineer
County of Los Angeles AD RESS ibJ/LIE�/
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. SUPT OF BU D_DING LOCALITY `
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION 7 OWNEft
BLOCK TRACT �J'/-IA �.I � � MAILAY e
�X
ADDRESS q70f D
NO. OF BlDGS.
SIZE OF LOT NOW ON LOi CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTORs-
ADDRE$�j'— p CONNECTION DATA
r CIT Y� OC77 STATION P� �•O DEPTH
❑ STATE ��. '® MANHOLE REFEREIJCE
REGISTRATION NO. C3 COUNTY %Y/ (j+ ] .V. R LOWER
TYPE OF CONNECTION LENGTH FROM /B e
No. I DESCRIPTION OF WORK FEE Y. k*aB 9; M.L.TO P.L.
/ HOUSE SEWER CONNECTING TO �) !A1y/, Ay FR B �M,,vA' �ir"7
_ PUBLIC SEWER Q $ 3.50 _ .J �
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 �j
CONNECT ADDITIONAL SLOG. OR CO. IMP. NO. - Jw
WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT 140.
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
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION TOTAL FEE V REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON. APPROVALS DATE INSFEC"OR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING WELLING
TO THE PUBLIC
�� (�/ NEW HOUSE SEWER 4d
SIGNED THIS DAY OF 19
OWNER OR �lJk�l/ CONNECT ADDITIONAL
OWNERS AG EN /ttiCL-� 1/ BUILDING OR WORK
�✓ /�A— SEPTIC TANK, SEEP, PIT($)
ADDRESS - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP LICATION CESSPOOL❑ DRYWELL❑
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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RED ED BY L S ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T 1 AM HE LEGAL OWNE F THE ABOVE
DESCRIBED RES TIAL PRO ERTY. BACKFILL SEPTIC TANKS❑
/. SEEP. PIT(S) ❑ CESOOLS❑
SIGNATURE SP
OF PER AIITTEE '
WILLIAM J. FOX, COUNTiEU61NEER VALIDATION
5 4 1 11^ Ja 7 4 4.50
'BT BY --
DEPUTY DEPUTY
:.By By
DEPUTY DEPUTY® � & A � Al
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