HomeMy Public PortalAbout10617 KEY WEST ST_Sewer__ CESOB
-62
76A642D APPLICATION FOR PERMIT _
6A642
COUNTY OF LOS ANGELES . SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING sJ /
JOHN A. LAMBIE, County Engineer ADDRESS �/
WILLIAM A. JENSEN, Sup't of Building ��
LOCALITY
NEAREST
FOR APPL C T TO FIL CRO55 S,
.
LEGAL Q J
DESCRIPTION LOT OWNER
MAIL
BLOCK TRACT 2 ADDRESS �F� f •7 /� �C/��
NO OF BLDGS I
SIZE OF LOT NOW ON LOT CITY TEL. NO. !� 3
USE OF
BUA DISTRICT Nd GROUP MAP PGPROCESSED BY
LDINGS J�/� -
BK
G j
CONTRACTOR / /4
ADDRESS CONNECTION DATA
CITY ��� TEL N. STATION DEPTH
El STATE
S1 � ❑ COUNTY MANHOLE REFERENCE UPPER
REGISTRATION NO
NO DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM q
HOUSE SEWER CONNECTING TO Y. URBP L M.L TO P.L. CXJ�
PUBLIC SEWER @ E5 00 O
SEPTIC TANK,SEEPAGE PIT OR P C NO.
PITS ANDOR DRAINFIELD @ $10 00 CO IMP NO JOB NO. ///---��� U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / _' C9
PRIVATE DISPOSAL SYSTEM @ S300 /
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W�IYER [�5[M EHT RECORD INSTR.NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN,CESSPOOL,DRYWELL MANHOLE @ 35 00
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 3300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE 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,IG, TORE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER ,/�C J" q�� 'i. -; •S{iti
OWNERS AGENT
� CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS,CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THELEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO E DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER -
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ / '`
SEEP.PIT(S) ❑ CESSPOOLS li �� •� .���`y_ ���
VALIDATION ROBERT'A. WOOD
CK M
SUPERVISING MECHANICAL ENGINEER
• O CASH
LI`1�ro 7 3 4 4 JUL 11 1 0 D 7.00-
�'