HomeMy Public PortalAbout9962 BROADWAY_Sewer__ ].Afi.Ga
caeoe.a.ae APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTB•IENT OF COUNTY ENGINEER .
BUILDING AND SAFETY DIVISION BUI LDIN6 '] pp
JOHN A. LAMBIE, County Euginaar ADDRESS .Z /V
CASSAT[ D. G=IN, SuP t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. ' OWNER
BLOCK TRACT ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF / - -' - --' "• -
BUILDINGS 7 DISTRICT NO.1 GROUP MAP PROCESSED BY
BK P6
j CONTRACTOR
ADDRESS Ff
CONNECTION DATA
CITY TEL. NO. Q/r STATION Zj DEPTH
STATE
REGISTRATION NO. 7oA COUNTY MANHOLE REFERENCE UPPER
NO. DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $3.00 TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. RB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD
EITN.,CESSPOOL.DRYWELL.MANHOLE N $2.00
HOUSE SEWER CONNECTING TO P. C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERM $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE LPA, REIMBURSEMENT FEE //jLeA
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. /��r
SIGNED THIS---'Z-DAY OF 19� NEW HOUSE SEWER (`xI�.PI�&I"
OWNER OR T CONNECT ADDITIONAL
OWNERS AGENT - RM E S Q01,V A( BUILDING OR WORK
ADDRESS 014 BE LU{} SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ T141S APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL(I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ 0 ���
SEEP. PIS) CESSPOOLS 1,6
_
SIGNATURE
T
OF PSEE MITTE '
®r VALMATION-----, ROBERTA.WOOD
CK. M.o. cASx// SUPERVISING MECHANICAL ENGINEER
LACD 5 0 2 5 5 JAN 11 i 0 A 5.0 0 .,