HomeMy Public PortalAbout9835 BROADWAY_Sewer__ O
SaE-663 1254- APPLICATIONFOR PERMIT
3 8 E.6t`
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
DepartmentCo=iy of Los
Engineer U- _
Couaty of Los Angeles no KESS f0 .35 cu,.zr,•s
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY •r
FOR APPLICANT TO FILL IN NEAREST
CR05S ST. iy
LEGAL /
DESCRIPTION LOT NO 16 OWNER
BLOCK TRACT �• 3 S MAIL y 5�
ADDRESS O OF y�
SIZE OF LOT 7 'r IlQ NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS �- DISTR]Cf NO. GROUP -A4A9'
BK PG
CONTRACTOR Y �,�.t y —2:7 C ,//�
ADDRESS i l ,Yj /CONNECTION DATA L C-�
CITY A— L. HO. v fCl�1+ STATION DEPTH
lC, G [:ISTATE ' ,r^- MANHOLE REFERENCE
REGISTRATION NO. / � ! y C3 COUNTY / ♦ iWPRR� LOWER
TYPE OF CONNECTION LENGTH FROM A�A
No. DESCRIPTION OF WORK FEE ' •Y� CURB 'err M.L. TO .L
HOUSE
t3(J
HOUSE SEWER CONNECTING TO �))
PUBLIC SEWER @] $ 3.50 _ry d
HOUSE SEWER CONNECTING TO - -
PRIVATE D1510SAL SYSTEM 1.00 _ �I✓J/
CONNECT ADDITIONAL BLDG. OR ,�—J� CO. IMP. NO. �s/ /Ui JOB. NO.
WORK TO HOUSE SEWER 1.00 (J fJ
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. ROAD PERMIT N0. pC
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00
PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
.P.ITS ANO/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DflYWELL —— WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PET _ CONNECTION CHARGE FEE
OWNER'S $ 00
AUTHORIZATION TOTAL FEE —6u REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER T
NEW HOUSE SEWER
SIGNED THIS DAY OF 79s�
OWNER Ofl CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS 56 TANO/OR DRgINFIELO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
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 i AM PROPERLY REGISTERED AND/OP DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO USG SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL ROPERT�Y. //'/�J�p�,�> BACKFILL SEPTIC TANKS❑
SIGNATURE
PERMITTEE /f .N�'�" SEEP. PIT(B) ❑ CESSPOOL �LIL /
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION
ado 4`0 4 2r, MAY 2.3 4 . 5.5 0
BY . . - .
DEPUTY._ DEPUTY
BY BY
'® DEPUTY DEPUTY