HomeMy Public PortalAbout9914 BROADWAY_Sewer__ �CEB08 5-55
76A642D APPLICATION FOR PERMI � {�
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BDILm NG r �,/
ADORES$
]OIIN A. LAA MIK, C I,ly E g
COLEMAN 6. IFNKIN, i,' (6Bild in
o @
LOCA LiTV
NEAREST
FOR APPLICANT TO FILL IN CflO55 ST v
LEGAL
OE5CRIFT ION LOT NO. OWNER
MAIL
BLOCK TRACT Q J ADDRESS
NO. OF CLOGS, r�
SIZE OF LOT NOW ON LOT CIT f/ TEL. NO. 117 -1W J
USE OF
BUILDINGS DISTRICT N . GRO MAP pROCE55E Y
K PIG
CONTRACTOR ��� /"/ � A
ADDRESS ((("' CONNECTION DATA
CITY TEL. NO. STATION DEPTH
LICENSE LICEN5E VPPER
NO. CLASS MANHOLE REFERENCE
OWZq
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOOSE SEWER CONNECTING TO YCURB P.L. M.L.TO P.L.
PUBLIC SEWER "' $ 5.00
SEPTIC TARX,SLEPAGE PIT OR P.C. NO.
PITS ANOIER ORAINFIEIC E- $10.00 CO. IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TOI TRUNK PERMIT NO ROAD PERMIT NO. v
L
PRIVATE DISPOSASYSTEM " $ 3.00
CON N ECT AEDITIONAL`pM�I� gFHDAVIT .Iv .SEI+[ RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER C $ 3.00I
PI OR ABANDON HOUSE U
SEWER OR DISPOSAL SYSTEM - $ 3,00 W
F OV � HWY. OR ST.WIDENING y
E%TN ,CESSPOOL. MANI+OLE @ $ 5.00 STATE ENCROACHMENT / Z
PERCOLATION TEST E $ 50G PE RM IT NO. J
NOVSTRIAL
WASTEAPPROVALj
OWNER'SI PERMIT $ 21 00 HA GES
AUTHORIZATION I TOTAL. FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE NSPECT-WG SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION Ary./OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ElDRYWELL [I
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM y '- /V• -( (
CALIFORNIA OR THAT! AM THE LEGAL O E OF, ANO INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB E DESCRIBED PES ENT L PRO EftTY.
ABA...N HOUSEBEWER
SIGNATURE ❑
L5
OF PERMITTEE_ BACKFILL SEPTIC TANKS
SEEP.PIT IS) LlCE55POOPERMITTEC_UL5 ❑
VALIDATIOON
CK. M.O. CASH
LAIL705" 3 1 R' OCT 17 1 0' 0 5.00- a
A
l
1
14650 INSERTS- A' /
CEBOB8-6O APPLICATION FOR PER Ii�ll T
7SA64ID SEWER-SEWAGE DISPOSAL 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y- a
ADDRESS
JOHN A. DENSE. County ofg it i
WILLIAM A. IENSEN. Supt of Buildivg LOCALITY
NEAREST AV
FOR APPLICANT TO FILL. IN CROSS ST.
LEGAL I�
DESCRIPTION LOT NO., 37 OWNER / /
BLOCK TRACT 80 s' 'MAIL
ADDRESS L.Y
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT 3 CITY TEL. N0.
USE OF '
BUILDINGS Mi a DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR ,p � 0�
ADDRESS CONNECTION DATA L I
CITY 11 ! TEL.N0. Tb STATION 7 3 • („ DEPTH T
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. / (/ / COUNTY G, WE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER
SEWERECONNECTING TOPUBLI@ $3.00 j
TYPE OF CTION LENGTH FROM /
SEPTIC TANK,SEEPAGE PIT OR - Y. RB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
HOUSE SEWER CONNECTING TO @ $2.00 1 } P C NO
PRIVATE DISPOSAL SYSTEM @ 11.00 CO.IMP. N0. d 7 JOB NO. S.
CONNECT ADDITIONAL BLDG.OR �� TRUNK PERMIT NO. ROAD PERMIT NO. V
WORK TO HOUSE SEWER @ 31.00
SEWER OR DISPOSAL SYSTEM HOUSE @ E 00 STATE ENCROACHMENT pt
PERMIT NO. O
INDUSTRIAL O
WASTE APPROVAL 14
CHARGES
&NNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING' DWELLING APPROVALS ATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _/ 4
SIGNED THIS��OF 1 NEW HOUSE SEWER / � // 1/OG
OWNER OR // A y CONNECT ADDITIONAL
rAGENTS AGENT (� NN CONNEBUILDITADG OR WORK
SEPTIC TANK,SEEP, PITS) I
S AHD/OR DRAINFIELD
EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONATE THAT THE ABOVE I5 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING R,REPAIR,SEWER OR
NG AND SEWERS. SEWAGE DISPOSAL SYSTEM
REBY CERTIFY T IAM PR RLY ST RED AND/OR DISCONNECT PLUG AND
ED AS REOUI Y LOSA L NTY AND STATE F ` ABANDON HOUSE SEWERRNIA OR i 1 AM THE LEG WNER HE A E BEO ID L PROPEBT BACKFILL SEPTIC TANKS ❑URE T SEEP. PIT(S) ❑ CESSPOOL
ROBERT A.
®6Y.U. ( G_SH TIS J SUPERVISING MECHANICAL ENGINEER
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