HomeMy Public PortalAbout9735 BROADWAY_Sewer__ j8g84.163
APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY �1
NEAREST
OR PLICA T" TO LL I , CROSS ST. '
LEGAL ?l. 1 OWNER
DESCRIPTION LO 0.
BLOCK TRACT MAIL
ADDPEB$
- NO. OF SLOGS. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF pl$TRIC NO. GROUP MAP
BUILDINGS t.CT NO
BK PG
' CONTRACTOR
VY
DATA T�
ADDRESS - STATION T Y 0 DEPTH KJ
CITY TEL. N0. O MANHOLE REFERENCE �I O UPP
f� ❑ STATE J LOWER
REG157RATION NO. //�y �� ❑ COUNTY '
No. DESCRIPTION OFNWON FEE
HOUSE SEWER CONNECTING TO I� TYPE OF N TION LENGTH FROM D /
PUBLIC SEWER @ $3.50 J Y. CURB P.L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD Q $3.00
OVER
LOW
EXTNF CESSPOOPAGE PIT. DRAINFIELD L,D YW ELL,MANHOLE Q 5 2.00 CO. IMP. N0. / /�� JOB NO,HOUSE SEER CONNECTI
PRIVATE DISPOSAL SYSTEMG TO @ $1.00 ' TRUNK PERMIT N0, ROAD PERMIT NO..
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $ 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM C $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 DO
AUTHORIZATION TOTAL FEE f
7 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 I f
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS AY OF 19 CONNECT ADDITIONAL J
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
S
ADDRESAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ '
AND STATE THAT THE ABOVE 15 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AN LES COUNTY D STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH AM THE E AL 0 NER THE ABOVE -
DESCRIBED RESID IAL BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK. ;.- loci
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