HomeMy Public PortalAbout9844 BROADWAY_Sewer__ • TEMPLE CETT' . .
CE8082
9.39 APPLICATION FOR 0®
ERIVII
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bm LmnG
ADDRESS
,ola LANmIe, covneg �y,o.
ATe. TEf'!PL
CASSATT Dildi
. GRIFFIN, Sup t Of Buaq LDCpLITY l
} FOR APPLICANT TO FILL, IN
NEAREST.LE AL
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DESCRIPTION LOT NO. OWNER
BLOCK TRACT O p� c•� MAIL p���( c
,+J QJ - ADORESSNO.OF BLDr
(/JJ G
SIZE OF LOT NOW ON LOTS CITY 7V107/2Kf e/7 TEL. NQ Cv6
'USE OF
BUILDINGS DISTRICT NO.I GROUP I
BK' PG MAP I� PROCESSED BY
S R
CONTRACTOR Y-7-Y-7-V
ADDRESS CONNECTION
CITY EL.N0. STATION DEPTH
STATE MANHOLE REFER? CE UPPER
REGISTRATION N0. ❑ COUNTYLOWER
NO. DESCRIPTION OF WORK FEE -
HOUSE EW ERCONNECTING TO �j ?3.00 � j
TYPE CONNECT ON LENGTH FROM
SEPTIC TANK, SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. /
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
p EKTN..CESSPOOL, DRYWE LL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N
` PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. OAD PERMIT NO.
( WORK TO HOUSE SEWER @ $L00
u SEWER HOUSE @ $100 •^ STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL -
WASTE APPR L
�q CHAR
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
,. AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT THE NAMED COW
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTIING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
b SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION /1
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY a CESSPOOL ❑ DRYWELL ❑ / l ,('JJ /Z
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. o SEWAGE DISPOSAL SYSTEM 1 I / f(///�✓
p bZ
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE
N ECTPLUG AND 1 /
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
CT PLUGHOUSE AND I I
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE TIAL PROPERTY. BACKFILL SEPT IC TANKS ❑
SIGNATURE C% SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE l��
®� L SUPERVISINNG MECHANICALO
OENGINEER
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