HomeMy Public PortalAbout10523 KEY WEST ST_Sewer__ &E-6D
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APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles F'ADDRESS
LDING J/5 E-''. �1 'lyC ��'
JOHN A LAMBIE, COUNTY ENGINEER r [Jy�.+ l n
® CASSATT D GRIFFIN, SUPT OF_SUILDING ALlT� / d/�� L �Y
FOR APPLICANT TO FILL IN CCROSS ST. 'A4 L J , .��4 X PLEGAL _�? I1�
DESCRIPTION LOT NO�j _6 '61 ` OWNER -���}�
MAIL
BLOCK TRACT , J ADDRESS
NO OF BLDGS / p ,r
SIZE OF LOT - NOW ON LOT CITY J l //' TEL NO
USE OF f DISTRICT NO I GROUP I MAP
BUILDINGS
y—� BK PG
CONTRACTOR
ADDRESSlI L1 "'•`� 3 ��" �r CONNECTION DATA
�� j�/7/
STAT10 -/ - DEPTH ,
CITY j� \/� EL NO / MANHOLE REFERENCE PPER
- ❑ STATE
REGISTRATION NO ❑ COUNTY ,
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF TION LENGTH-FROM '
Y. CURB" P L M L TO P L
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00 '
OVERFLOW SEEPAGE PIT, DRAINFIELD ,
P
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO IMP No
IMP NO _��JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $100 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 UO / WASTE APPROVAL
CHARGES
`15 CONNECTION CHARGE FEE -_
OWNER'S 1 PERMIT $ 1 ,00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE a
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 NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR ' BUILDING OR WORK
OWNERS AGENT— SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I RAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS I SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM, PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE 'LEGAL OWNER F TH ?ABOVE
(;F
SCRIBED RESIDENTIAL OPERTY , - BACKFILL SEPTIC TANKS i
NATURE SEEP PIT(S) ❑ CESSPO LS❑ O _
PERMITTEE '
JOHN A LAMBIE. COUNTY ENGINEER "'VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N O CASH
LA65258N SEP2910 A 450 M