HomeMy Public PortalAbout9850 BROADWAY_Sewer__ °
5aE.6B - APPLICATION FOR PERMIT
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68 .BDIVISION 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
FICANTTO FILL IN CROSS sr
ORAPPL .
.LEGAL OWNER
DESCRIPTION LOT NO,
MAIL
BLOCKTRACT f '' ADDRESS
OX o� N0. OF ]SLOGSCITY TEL. N0.
SIZE OF LOT(rJ / O NOW ON LOT
USE OF tJJ `DISTRICT NO. GROUP MAP
BUILDINGS _
BK PG
CONTRACTOR Q-
ADDREss � 9�/ a CONNECTION DATA '
�—� STATION �f�� DEPTH
CITY�p`j.AQ�G TEL. N0. /
cc.•`""55
UPPER
STATE MANHOLE REFERENCE .y�.� /
REGISTRATION NO. ❑ COUNTY
ND. DESCRIPTION OF WORK FEE I TYPE O!HOUSE SEWER CONNECTING TO I TYPE OF R CTION LENGTH FROM /
Y. � P.L. M.L.TO P.L.
PUBLIC SEWER @ g 3.50 Q
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
E%TN.,CESSPOOL.DRYWELL,MANHOLE n $2.00 CO. IMP. NO. % '��i. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ s 1.00 TRUNK PERMIT NO ROAD PERMIT NO 41 jV l 1
J CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT f
/ WORK TO HOUSE SEWER @ $1.00 -0 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION
REIMBURSEMENT FEE
TOTAL FEE �j
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC 5EWER L^J NEW HOUSE SEWER r]'
SIGNED THIS —DAY 0 �1� CONNECT ADDITIONAL
OWNER OR //J BUILDING OR WORK
OWNERS SEPTIC TANK.SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELO
I HEREBY KNOWLEDGE HAT I HAVE READ TA IS APPLICATION CESSPOOL ElDRYWELL El
ANDTHAT 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 piSCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISC ON HOUSE SEWER
CALIFORNIA OR THAT 1 THE LEGAL OWNER 0 THE ABOVE
DESCRIBED RESIDENTIA R PERTY. BACKFILL SEPTIC TANKS❑
I. SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS EJ+'
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK.
LACo 5 3 1 2 FEB 19 4 5.5 0. �+