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HomeMy Public PortalAbout10669 KEY WEST ST_Sewer__ D 5&E-689 11.98 APPLICATION FOR PERM-IT., S&E•8 7- DIVISION OF BUILDING AND SAFETY ' SEWER—SEWAGE DISPOSAL �IIY 'Department of County Engineer County of Los AngelesBUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ® CASSATT D. GRIFFIN, SUP'T OF BUILDING LOCALITYNEAREST - FOR APPLICANT TO FILL IN CROSS ST, LEGAL OWNER DESCRIPTION LOT NO. �j -c4- 1 (76' L�,l�✓1J`!r �d d,{(i' lbs, MAIL BLOCK TRACT 2 ADDRESS / NO. OF BLDGS. CITY TEL. NO. SIZE OF LOT' ,Jl qo NOW ON LOT USE OF BUILDINGS DISTRICT NGROUP MAP ir 1 '�r /� r O. CONTRACTOR ADDRESS , CONNECTION DATA � STATION DEPTH CITY 4�' - NO. _ MANHOLE'REFERENCE I UPPER ' ATE 1 O ER REGISTRATION NO. ❑ COUNTY . NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF ION LENGTH FROM �Q PUBLIC SEWER @ $3.50 t' Y. CURB P.L. M.L. TO P.L. (J SEPTIC TANK,SEEPAGE PIT OR PITS-AND/OR DRAINFIELD Q $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD ?' P. C. NO. EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 CO. IMP. NO. ��/� JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEMQ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. , CONNECT ADDITIONAL BLDG.ORS' STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL , SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 1 00 AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE " 1 HAVE'AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS. DATE INSPECTOR'S SIGNATURE TRACTOR TO AEWOVE D BED EXISTING DWELLING Q ar TO THE PUBLINEW HOUSE SEWERSIGNED THIS 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGEENSEPTIC TANK,SEEP, PIT(S) ADDRESS 4 AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT r HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ;i�gD/OR DISCONNECT PLUG AND LICENSgD AS REQUIRED- BY LOS ANGLES COUNTY AND\ST1F7E OF C•ALrFORJJIAyOR�`THAt'11z AM',1THS3 'ALh OWN6RNOF`1THE 'ABOVE ABANDON HOUSE SEWER DESCRIBED RES I'DEN TJA- PRO PERT f/ BACKFILL (SEP ❑ CESSPOOLS ��• SIGNATURE � � OF PERMITTEE JOHN A. LAMBIE, COUNTY. NGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. 'INSPECTOR CK. M.O. CASH - 1 I ©0.3 3'.0 SEP 19 4 k 4-5 0 "n