HomeMy Public PortalAbout9851 BROADWAY_Sewer__ y
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL p
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION i
COUNTY OF, LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING p -
ADDRESS ^ Q I
FOR APrPLICLAN FILL, LOCALITY
BUILDINGNEAREST
ADDRESS d/ ��,/ ! 4 / CROSS ST.
LOCALITY -/ G p DISTRICT NO. SERIAL NO. PERMITNO.NO.
NEAREST P� 15- A I95
CROSS
ST.�� /) RECEIVED BY Ready tar Inspection DATEISSUED
OWNER
MAIL /�/ ll % USE ZONE OCCUPANOY BI(MAP PG
ADDRESS r/ ///� ,,��
CITY ��'1A0/K��{`!.�< L.NO. —I t�
CONTRACTOR ,p�.�I, �� }0" A,
ADO RESS i��i�alJ" � ..7 JOB NO."
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CITY�� /10 �fy'TEI.NO. TRUNK PERMIT NO.—
STATE 4 Z_C
REGISTRATION N0. ' Q� COUNTY ROAD PERMIT N0. 2 aJ rc.,Jc
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DESCRLEGIPTION LOT N0. �.A STATE ENCROACHMENT
✓ PERMIT NO.
BLOCK TRACT i3�o.� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTNO.OF BLOCS.
S YI DO 110W;O.NNLOT `a(J CHARGES
BUILDINGS
CO NN ECTI HARGE FEE
NO. DESCRIPTION OF WORK FEES
HOUSE SEWER CONNECTING TO ��TT REIMBURSEMENT FE
PUBLICSEWER Q S 3.50 RECEIPT NO. I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL BY87EM 1.00
CONNECT ADDITIONAL BLDG.ORXCEPTION RECORDED
WORK TO HOUSE SEWER LOD / d9 a' N0. DATE I BY
ALTER OR REPAIR EXISTING
_SEWER OR DISPOSAL SYSTEM 1.00 _
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION- DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00
STATION -`. DEPTH
UESSPOOL-DRYWELL
SPECIAL
SPECIAL CONDITIONS ONLY 2.00 '�} I 1./ 0 MA�EFERENCE
^^Y TYPE OFNO ECTIO k_' LENGTH FROM C30OWNER$ PERMIT { I X�00 A= M.L.TO P.L.
AUTHORIZATION TOTAL FEE
AHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE
SIGNED THIS.__1 ..DAY%QF...../���.._...._.__.---- 19.f� NEW HOUSE SEWER
OWNER OR //`` G _ ���' �� / CONNECT ADDITIONAL
OWNERS AGENT,(f—.....�,: _e. BUILDING OR WORK
SEPTI CT ANK,SEIELD (S)
ADDRE58__n..:/..�n_..Sa�_�.�1[...rCJ..�.!�..f�e'S.�_!.-l.P.ay... pND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL E] DRYWELL �—
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO.COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER. REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND.
AND/OR LICENSED AS REQUIRED%BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE Of CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE A80YE DESCRIBED R ENTIAL PROPERTY. BACKFILL SEPTIC TANKS El
S
SIGNATURE /"meq- A ,{�f/� B ' '� / ' SEEP.PIT(S)Q CESSPOOLS
OF PERMITTEE__.?0_ �_.!...'.(. ....... �:..-_--------
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