HomeMy Public PortalAbout9448 KENNERLY ST_Sewer__ C
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1SA642D .,APPLICATION FOR PERMI
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADD REss G..
COLEMAN W. JENKINS. SUPT, OF BUILDING
LOCALITY
IN
/ r
FOR APPLICANT TO FILL IN CROSS ST. L�.
LEGAL
DESCRIPTION LOT NO }' OWNER
MAIL
BLOCK TRACT �CJ^ ADDRESS
o NO OF BLDGS.
SIZE OF LOT 60 X i p _NO W ON LOT CITY TEL NO.
USE OF , DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS �y�j
BK PG
CONTRACTOR
5,DO �-�-•' 6 //J
ADDRESS (✓ qp CONNECTION DATA V
CITY TEL NO STATION v/.� 1 6 DEPTH l
STATELIC MANHOLE REFERENCE PPE
LIC EN 5E NO_ � CLASS LOWER
NO I DESC IPTION OF WORK FEE TYPE OF CONNECTIO etNGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P M L.TO P L. 2A.
7 d
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR O
PITS AND/OR DRAINFIELD @ 51000 CO IMP. NO O. /V 11 Q V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO, ix
PRIVATE DISPOSAL SYSTEM @ S3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEN[N1 RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN C ESSPOOL,DRYWELL.MANHOLE @ $500 a'
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ i 00
CONNECTION CHARGE FEE
AUTHORIZATION rTOTAL 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
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL C ��'•/�1'� /
ADDRESS BUILDING OR WORK (r �
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOV D SC BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MffTEE SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
M O. CASH SUPERVISING MECHANICAL ENGINEER
K.
Lf C, 6 4 8 s� 19 �. Q 5.0,0-