HomeMy Public PortalAbout9823 BROADWAY_Sewer__ D l
CE6•09PPLICATION FOR PERMI�
TBAeazD APPLICATION
OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �Q n
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 7 Cl /T
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY L TV
NEAREST
FOR APPLICANT TO FII.L IN CROSS ST.
AL 2
DE BC RGPTION LOT NO. I
OWNEfl
MAIL
BLOCK TRACT �� �a bJ ADDRESS
NO. OF BL 11 y� pp
SIZE OF LOT Q �J NOW ON LOT ` CITY �y I (i O.
USE OF DISTRICT NO, GROUP M P PROCESSED BY
BU ILOINGS
/�/�J�J BK PG
CONTRACTORiv 1 N Q L`� `� F '-
ADDRESSS C vc / CONNECTION DATA
CITY y� TEL. NO. �Oq ' 2 STATION .T + / DEPTH 6
STATE �] �` J^ U UPPER
LICENSE NO. ,[a CLASS '�_T MANHOLEREFERENCE T LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOB SE SEW ER C O N N E CT I No TO Y. P.L. M.L.TO P.L. 1
PV BLIC SEW ER ® 33.00
SEPTIC TANK.SEEPAGE PIT DR P.C.NO. O
CO. IMP. NO. JOB NO.
PITS AND/OR GRAINFIELD 310.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM ® 39.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVII [ASUI[x. RECORD.INSTR,NO. DATE F
WORK TO HOUSE SEW ER E3.00 U
OVERFLOW SEEPAGE PIT.ONANFIEL. W
%TN.,CESSPOOL.DRYWELL.MANHOLE® SS.00 d
ALTE BR.ODN HOUSE HWY.OR ST.WIDENING Z
B R OR DISPOSAL SYSTEM ® E3.00 OO STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL FEE I OO CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. 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,PITIS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM P PER REGISTERED ANO/Ofl ALTER, REPAIR.SEW ER OR
LICENSED AS REQUIRED BY LOS GLES OUNTV AND STATE OF SEWAGE DISPOB ALSYSTEM , L
CALIFORNIA OR THAT AM THE GAL O ER OF,. ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE ES ED RE ENT4 ROPERTY, ABANDON HOUSE SEW ER
51 GNATURE ❑
OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS ❑
ALMITION JACK R. ALLEN
cpsH
SUPERVISING MECHANICAL ENGINEER
LAC05 2 5 4:o JU428 1 0 D 5.00- 4