HomeMy Public PortalAbout9945 BROADWAY_Sewer__ 4
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ESe66.6D APPLICATION FOR PERMIT
76AS42D COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION au 1LDiNG j'
AOORE59
JOHN A. E. County Engineer P _
WILLIAM A.. JENSIEN$EN. Supt of Bmlding LOCALITY'
. ,.. ICITY
NEAREST
FOR APPLICANT TO FII L IN CROSS ST.LEGALOWNER eOESLRILOT N0.BLOCK TRACT ' S MAIL
ADDRESS
NO.OF BLDGS.SIZE OF LOT NOW ON LOT �/ TEL. N0,
USE OFrJ '�DISTRICT NO. GROUP MAP P CESSED BY
CONTRACTORBK PG
ADDRESS
/ i CONNECTION DATA
CITY ��/ .N.O}.'; / �I '� 71 STATION 3 DEPTH
REGISTRATION NO. r9® COVNTY MANHOLE REFERENCE ' LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE aa
SEWER
CONNECTING TO
PUBLIC CSEWER4
@ $3.00 0
TYPE OF CTION LENGTH FROM
PITS
SEPTIAND/ORD AI N FIELDC TANK.SEEPAGE T OR @ 83.00 Y. CUR P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EKTN..CESSPOOL.DRYWELL @ 32.00
HOUSE SEWER CONNECTING TO P.C.NO.
CO. IMP. NO. JOB NO. 6.
PRIVATE DISPOSAL SYSTEM @ 81.00 0.
J CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. C.
ROAD PERMIT NO. U
WORK TO HOUSE SEWER @ $1.00 dQ
SEWER.REPAIR CR ABANDON HOUSE @ SI 00 STATE ENCROACHMENT
PERMIT N0, N
INDUSTRIAL V
WASTE APPROVAL a
CHARGES
OWNER'S PERMIT S 2 UU CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 0 15 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCHaED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SE
SIGNED THIS - DAY OF 19� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
ADDRESS rD SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HERE911" KNOWLEDGE THAT 1 HAVE. READ T S APPLICATION
I,. AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
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 ANGEL I STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M THE LE L R 0 THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDENTI P OPEATY. SEEP. PITS ❑ CESSPOOLS Q
SIGNATURE -
OF PER MITTE
®= VAL ] ROBERT WOOD
CK. M.
0.a. (1 CASH
sx// SUPERVISING MECHANICAL ENGINEER
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