HomeMy Public PortalAbout9957 BROADWAY_Sewer__ /A�
D
CE808 APPLICATI(o N FOR ;ERMIT
seoe e.se COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
]SSA A. GRIFFIAMBIE,N,
Countv, Supt of luiler
CASSATT D. GRIFFIN, Sup t of Buildivg LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
r li/.52
AL
DESLEGPTION LOT NO. o OWNERS
BLOCK TRACT
( f ,J O S ADORES MAILJ / �J
SIZE OF LOT O/� / ^ NOW S ON LOTCITY EL. NO. / fJ J
USE OF
CONTRACTOR
$ DISTRICT ISO. GROUP I BK MAP �� I '2CE BY
CONTRACTOR Q DISTRICT)
ADDRESS q'lr j / CONNECTION DATA
Ci7Y
TFL.NO.G �� O STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,
PITS AND/OR DRAINFGELDT OR @ $300 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.ORI �-V TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DIISPOSA L SYSTEM T . REPAIOR ABANDONNOUSE @ $100
STATE ENCROACHMENT
PERMIT N0.
INOU STRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT $ �p 2 `L1 DD CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE cJ OREIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY O 19�o NEW HOUSE SEWER
OWNER OR l CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS S� SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPL ATION
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ECT PLUG AND
ONN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
ON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE L AL 0 NER OF THE ABOVE
DESCRIBED RESID1�E1NTIAL PROPERTY. _ BACKFILL SEPTIC TANKS ❑
SIGNATURE � SEEP.PITS) ❑ CESSPOOLS ❑
OF PERMITTEE
®' VALIDATION\ ROBERT A. WOOD
CK. tl.o. —H SUPERVISING SUPERVISING MECHANICAL ENGINEER
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