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Home My Public Portal About9845 BROADWAY_Sewer__ . ° 5&E6APPLICATION FOR PERMIT DIVISION OF BUUMING AND SAFETY SEWER—SEWAGE DISPOSAL Department of Couaty Engineer County of Los Angeles BUILDING S WM.J. FOX, COUNTY ENGINEER ADDRESS CASBATT D. GRIFFIN, SUPT of BUILDING LOCALITY / FOR APPLICANT TO FILL IN cuoss T. ST AL –DESCRIPTION LOT NO. _ OWNER r BLOCK TRACT 3MAIL 9 /� �— NO. OF SLOGS. ADDRESS fr SIZE 0 NOW ON LOT CITY TEL. N0. USE OF BUILDINGS _ ,•v DISTRICT NO. GROUP MAP BP CONTRACTOR �y L Lf♦//jy7n/� 5 L rr ADDRESS % /s ,>11 a.. ..,_. +. ` CONNECTION DATA C _ CITY •�i -/„� TEL. NO. STATION ��7H ,lJ DEPTH [I STATEREGISTRATION N0. 3 6 ❑ COUNTY [(t A EI NppEp REFERENCE D6filR YYY TYPEO NNECTI N LENGTH FROM NO. DESCRIPTION OF WORK FEE Y. UR p.L. M.L.TO P.L. HOUSE SEWER CONNECTING TO D PUBLIC SEWER © $ 3.50 HOUSE SEWER CONNECTING TO , _ PRIVATE DISPOSAL SYSTEM 1.00 L CONNECT ADDITIONAL BLDG. OR �[z CO. IMP. NO. / /C+J JOB. N0. WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING _ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. �V l 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- ORYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES PERMIT CONNECTION CHARGE FEE OWNER'S $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPE TOR'S SIGNATURE TO THE PUBLIC SEWER /� � $IGNED THIS�'P'�DAY OF C'^ -- ,AA 19 r�_ NEW HOUSE SEVER "SS OWNER OR aJ eat CON DIN ADDITIONAL OWNERS AGENT v �` �It ei j�� BUILDING D WORK ADD6E5$ Q p - tJt +'F +�y=• .*-af { (O.� SEPTIC TANK, SEEP, PIT(S) AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS'IAPPLI CATION r 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 I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF pISCONDISCONN HOUSE SEWER I CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ SEEP. PIT(,) ❑ CESSPOOL5.0 2I1( J Y.I+H_��Q•/.-�-�—� SIGNATURE OF PERMITTEE WILLIAM J. FOX,COUNTY ENGINEER VALIDATION BY _Ao7B� 5 215-' AUG 25j a 5_ .50 1/-�, DEPUTY \L DEPUTY -BY BY 0 DEPUTY DEPUTY