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HomeMy Public PortalAbout9921 BROADWAY_Sewer__ E- Sa E66 APPLICATION FOR PERMIT '1 68DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL 3 Deportinent of County Engineer County of Los Angeles BUILDING 9921 ,QA JOHN A. LAMBIE, COUNTY ENGINEERr— CASSATT ADDRESS 7 ® D. GRIFFIN. SUPT OF BUILDING LOCALITY�— FOR APPLICANT TO FILL IN CROSS ST. LEGAL �^ eo DESCRIPTION LOT NO. OWNER /�—AjMAILR BLOCK TRACTI�1� i1' ADDRESS A 4 77 N0i00F BLLDGS. CITY - TEL. NO. SIZE OF LOT NOON OT USE OF DISTRICT N0, GROUP MAP 'U'L"NGS �/'Y-- �$K PG CONTRACTOR ' / ADDRESS CONNECTION DATA If CITY L{a, il)1 NO.� STATION DEPTH MANHOLE REFERENCE UPPER STATE LOWER REGISTRATION NO. ❑ COUNTY . No. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM PUBLIC SEWER @ ,� Y. CURB P.L. M.L.TO P.L. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR GRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, GRAINFIELD P. C. N EXTN.,CESSPOOL,DRYWELL,MANHOLE C. $2.00CO. IMP. N0. JOB N0. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM rGii $1.00 ' TRUNK PERMIT NO. ROAD PERMIT NO. CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER @ $LOG PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM ©i $LOQ B WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 00 AUTHORIZATION TOTAL FEE O� REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. NEW HOUSE SEWER SIGNED THIS DAY OF 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK O OWNERS AGENT SEPTIC TANK,SEEP,PI (S) ` ADDRESS AND/OR DRAINFIELD HEREBY ACKNOWLEDGE LEDGE THAT 1 HAVE READ THIS APPLICATION 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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS AN EL UNTY AND STATE OF DISCONNECT CT PLUGHOUSE AND CALIFORNIA OR THAT I M L NER OF THE ABOVE WER DESCRIBED RESIDENT[ BACKSEEPFIL PIT( TIC S) CESSPOOLS Cl [ISIGNATURE OF PERMITTE JOHN A. LAMBIE, CO Y ENG EER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR _ CK. N, 0. CASH LACD 5 5 0 9 OGT 610 A 3.00 n