HomeMy Public PortalAbout9561 KENNERLY ST_Sewer__ 24650 INSERTS ,v
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76AG42DGo APPLICATION FOR C®E R WI T'
COUNTY OF LOS ANGELES SEWED—SEWAGE, DISPOSAL
DEPARTMENT-OF COUNTY ENGINEER
UI
BUILDING AND SAFETY DIVISION AD RE SG I
IOHN A. LAMBIE. County Enggm� ear
WILLIAM A. IENSEN, Supt of Badding LOCALITY
NEAREST
FOR APPLICANT TO FILL INceoss sr
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAI1349 L '
ADDRESS
NO OF BLDGS '
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP K M P PG PRQCESSE9
BY
CONTRACTOR
r hhh c
ADDRESS CONNECTION DATA
CITY TEL NO 4 2 STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 YPE OF CONNECTION LENGTH FROM -
SEPTIC TANK SEEPAGE PIT OR r CURB P L. M L TO P L.
PITS AND/OR DRAINFIELD @ $3 00
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 ORTRUNK PERMIT NO ROAD PERMIT N0. . p
WORK TO HOUSE SEWER @ $1 00 C1
SEWER OR DISIR OR ABANDON POSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT 14
PERMIT NO O
INDUSTRIAL EEC..
WASTE APPROVAL W
CHARGES N
OWNER'S PERMIT s 2 00 CONNECTION CHARGE FEE j
' AUTHORIZATION rTOTAL FEE REIMBURSEMENT FEE /
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ �✓
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING • APPROVALS - DATE!/ INSPECTOR'S SIGNATURf E _
TO THE PUBLIC SEWER o""
SIGNED-THIS DA OF 9= NEW HOUSE SEWER
✓ r
-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - - BUILDING OR WORK -
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE-IS`CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑ ,�'� '
WITH ALL COUNTY ORDINANCES AND STATE LAWS R ATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS r - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY T I AM PROP E STERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIR Y LOS ANGE S C N Y AND.STATE F ABANDON HOUSE SEWER
CALIFORNIA OR TH AM THE L AL N OF THE A E BACKFILL SEPTIC TANKS Cl
DESCRIBED RESIDE PROPERTY. SEEP PIT(S) _❑ CESSPOOLS ❑' J, y ''�!I4 �"'
SIGNATURE
OF PERMITY
®p DATIOV--� ROBERT A. WOOD
e m o, GSH SUPERVISING MECHANICAL ENGINEER
f r�
1 0 3 �G ;., i4 fi. �� 0 5 !7"'