HomeMy Public PortalAbout9969 BROADWAY_Sewer__ 76A 6420 -'CEBOe - 9/73 P
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APPLICATION OR FERMI
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIL ss (.d
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FOR APPLICANT TO FILL IN Laos:S:T.
LEGAL
DESCRIP[I ON LOT NO. OWNER
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BLOCK TRACT
1 j'�OcZ ADDRESS �p�VF\�``,fJ�
SIZE OF LOT
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NO
LOTS d CIT~;CMPI.lLC� TEL. NO. "L�1 \ 1�
USE OF
BUILDINGS 019 TRICT NO, GROUP M<P ESSEO BY
1�/� (t'17— TA Bx PS
CONTRACTOR Ac_Mcl UOV L /
ADDRESS c r W CONNECTION DATA
CITY PL TEL. NO. Ci q r , STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO, ILP SB •'�� LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CO NNEC LENGTH FROM
MOUSE SEWER CONNECTING TO Y. CURB PILI.4,J M.L.TO P.L.
PUBLIC SEWER ® $7,00
O.
PEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. BNO.
PITS E SEWEGRAINFIELD OECTIQ 310.00
HOUSE SEWER CONNECTING TO TRUNK PERMITO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM f3OO
CONNECT ADDITIONAL:LOG.OR AFFIDAVIT wMv[[ [Af{ RFQORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ® $
3.00 [ d
OVERFLOW SEEPAGE PIT.GRAINFIELD O
EKTN..CESSPOOL.DRYWELL. ® $5.00 CD
ALTER.RErR[R-:R�ABANDOM HOUSE HWT.OR ST.WIDENING
SEWERO SYSTEM Q $3.00 V STATE ENCROACHMENT H0.
MANHOLE ® $7,00 PERMIT NO. (j
INDUSTRIAL W
1
WASTE APPROVAL (q
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OWNER'S PEAMIT s 3 00 CHARGES
AUTHORIZATION TOTAL FEE OO CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR .�pM' _ NEW HOUSE SEWER '
OWNERS AGENT RsvJD ./J �� CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(5)
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER�BEW EP•��
LICENSED AS REOUIREO BY LOS ANGLES COUNTY AND STATE OF f SYSTEM 7�7
CALIFCANIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO pISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS cl
OF PESR41E �'
SEEP.PITT CESSPOOLS ❑
VALIDATION cx. •^, M,O, CASH
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