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HomeMy Public PortalAbout9956 BROADWAY_Sewer__ 7GAE`63;=."< APPLICATION YOR PERMIT 1 DIVISION OF BUILDING AND SAFETY SEINER—SEWAGE DISPOSAL • Deportment of County Engineof County of Los Angeles BUILDING �� ���� ADDRESS SSA J. FOX, COUNTY ENGINEER , CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY J � �� � �t FOR APPLICANT TO FILL IN NEAREST (�Q I` � ' CROSS ST.� Til/� LEGAL �,p J OWNER YY' i����. DESCRIPTION LOT NO.41gY�{ C.' BLOCK TRACT /3 S-©,S` ADORMAILES"''y''' fl-�f Gam- NO. OF BLOTS. / / - C SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF DI W e ' BUILDINGS /(/ / DISTRICT NO. GROUP MAP BK PG CONTRACTOR - j�Sj1e �� / J� Jr / ' ADDRESS /�i L� �9 q CONNECTION DATA CITY CQ �t �( TEL. NOPr— 77-14 / STATION /��5-y DEPTH O I � sEl .3- MANPPERREFEREN CE REGISTRATION N0. COUNTY / % 1- / INU � R TYPE OF CONNECTIO LENGTH FROM NO. DESCRIPTION OF WORK FEE Y CURB M L TD P L c$O HOUSE SEWER CONNECTING TOPUBLI (' /) ; HOUSE EWER Q $ 3.50 ✓ !J HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 _ CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. / '76JOB. NO. _ WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0. Gf !O DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR GRAINFIELD 2.00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT 5 1 00 AUTHORIZATION TOTAL FEE LJ( ftJ REIMBURSEMENT FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSP TOR'S SIGNATURE TO THE PUBLIC S W SIGNED THIS DAY OF '✓ 19�jyy NEW HOUSE SEWER q�Lq "s r OWNER OR -_-_---L CONNECT ADDITIONAL y OWNERS AGENT BUILDING OR WORK SEPTIC TANK, SEEP, PIT(S) ADDRES J412 AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HA E READ THIS APPLICATION CESSPOOL ElDRYWELL❑ AND STATE THAT THE ABOVE IS CORK CT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR _ PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTI THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS PEp 1 D BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER 1 CALIFORNIA O TH T 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RE DE1 IAL PROPERTY. BACKFILL SEPTIC TANKS❑ '1 SEEP.PIT(S) ❑ CESSPOOLS 10 2a? -d- SIGNATURE �. ,/ OF PERMITT , �`^-� WILLIAM J. FOX, COUNTY ENGINEER VALIDATION BY .. {�09 187 ' OCT 19 4 4.5 0 ID DEPUTY DEPUTY BY BY /�n / © DEPUTY . CJ"/•"+✓ '- DEPUTY