HomeMy Public PortalAbout10663 KEY WEST ST_Sewer__ A6 ,D_g2
T6Ae42o APPLICATION FOR PER , IT -
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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 ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T- `
LEGAL
DESCRIPTION LOT N_O / OWNER �� �`y
f
BLOCK TRACT / �(P� MAILADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY TEL NO.
USE OF `l' fi/n DISTRICT NO GROUP .MAP PROCESSED BY
BUILDINGS u7J ISK fPG
CONTRACTOR
ADDRESS f` jr� , CO/NN/-ECTILO/N DATA
�t ��� �� STATION f� DEPTH
CITY` � i TEL NO.014
STATE PPER
MANHOLE REFERENCE
REGISTRATION NO ` ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF N CTION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y URB P L. M L TO P L V
PUBLIC SEWER @ $5 00 PC NO. cy
SEPTIC TANK,SEEPAGE PIT OR CO IMP.NO _ JOB NO O
PITS AND/OR"DRAINFIELD -� $1000 ' -
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT
PRIVATE DISPOSAL SYSTEM @ E3 00 / LLLLLLJJJ
CONNECT ADDITIONAL BLDG OR AFFIDAVITWAIVER EASEMExT RECORD INSTR NO DATE d
WORK OHOOUSE SEWER @ $300 y
OVERFLOW SEEPAGE PIT,DRAINFIELD G
EXTN,CESSPOOL.DRYWELL.,MANHOLE @ $500
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 53 00 STATE ENCROACHMENT
PERMIT NO '
... INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S 2 00 CHARGES
AUTHORIZATION .TOTAL FEE CONNECTION CHARGE FEE `
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CONREIMBURSEMENT FEE
.TR -ACTOR TO CONNECT THE ABOVE DESCRIBED,EXISTIN DWELLING.
TO THE PUBLIC SEWJ APPROVALS- D TE INSPECTOR'S SIGNA U E
_SIGNED THIS DAY OF 19_ 6
*OWNER OR NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNERS AGENT
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION -AND/OR DRAINFIELD _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY'O RD INAN C ES' AND STATE LAWS REGULATING
PLUMBING AND SEWERS _CESSPOOL E:1 DRYWELL [:1
I HEREBY 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 ORTHAT M THE"LEGAL GVVWMR OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABC
B E ESCRIBED-R ENT}y PROPERTY ABANDON HOUSE SEWER
SIGNATURE ! BACKFILL SEPTIC TANKS
OF PERMITTEE - SEEP.PIT IS) ❑ CESSPOOLS ❑
ROB
�1VALIDATION wooer J�
SUPERVISING
MECHANICAL ENGINEER
CK M O. CASH
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