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HomeMy Public PortalAbout10674 KEY WEST ST_Sewer__ 76A 642D-CE808 -10-71 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEW AE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING / o� ADDRESS O6 e6 LOCALITY C/ ' NEAREST FOR APPLICANT TO FILL IN CR. /Y10 STAT LEGAL © /. -- DES CRIPTION DESCRIPTION LOT NO OWNER /qywMAIL BLOCK TRACT M • ADDRESS NO OF BLDGS SIZE OF LOT 6 NOW ON LOT CITY TEL. NO USE OF BK BUILDINGS DISTRICT NO GROUP MAP PG PROCESSED BY CONTRACTOR / QN �fLtlC Ft 6A/ ADDRESS'S /�--�g.ea 4 CONNECTION DATA CITY C/w'(T./ .�f,�� TEL NO41 1 5-,Y-7 7-Z STATION , 6? DEPTH STATE LIC / r / UPPER LICENSE NO Q S - GLASS f MANHOLE REFERENCE NO DESCRIPTION OF WORK FEE TYPE OF-CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO CURB P. M.L TOP L PUBLIC SEWER $7.00 P C.NO. SEPTIC SANK,SEEPAGE PIT OR CO IMPNOZ- JOB NO PITS AND/OR DRAINFIELD @ 510 00 . . } HOUSE SEWER CONNECTING TO- TRUNK PERMIT NO ROAD PERMIT NO d PRIVATE DISPOSAL SYSTEM @ 53 00 O CONNECT ADDITIONAL BLDG OR AFFIDAVIT wA1vEF -EASEMENT RECORD INSTR NO DATE (). WORK TO HOUSE SEWER @ $300 O OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN CESSPOOL DRYWELL @ S500 O ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING )--. SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT W MANHOLE $7.00 PERMIT NO h C INDUSTRIAL Z WASTE APPROVAL OWNER'S PERMIT f 3 00 CONNECTION CHARGE FEE CHARGES. AUTHORIZATION I TOTAL FE IHAVE 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 INS CTOR' IGNATURE SIGNED THIS� _DAY OF / >I • 1913 OWN RR ^ NEW HOUSE SEWER ~ OWNERS AGENT ` CONNECT ADDITIONAL BUILDING OR WORK ADDRESS 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 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYW ELL-❑ 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 THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND RESIDE IN. THE ABOV ESCRIB D RESIDENT TY PR RTY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITTEE SEEP PIT 115, SPOOLS ❑ VALIDATION CK. M.O; CASH r — ; , 76A 642D -C E808-10-7 1 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY •- L �� NEAREST FOR 'APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT. !� \Q� ADDRESSNO ' SIZE OF LOT S ( NOWOONB LOTS / err /r�(�-N 'L. CITY TEL NO. USE OF BUILDINGS DISTRICT/NO GROUP MAP // PROCESSED BY SK CONTRACTOR A ) U ') li L_5L ADDRESS .Z , ✓` CONNECTION DATA CITYC * TEL NO. � �7/ STATION P DEPTH UPPER STATE r1��� LIC I MANHOLE REFERENCE LICENSE NO d- GLASS NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGT FROM HOUSE SEWER CONNECTING TO 7 Y. CURB P•L M L T P L PUBLIC SEWER @ $7.00 P G.NO SEPTIC SEEPAGE PIT OR PITS AND/OR DRAINFIELD $10 00 .Co IMP NO. .108 NO HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM $300 TRUNK PERMIT NO ROAD PERMIT NO � d ���JJJJ O. CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER "-EASEMENT RECORD.INSTR NO DATE U WORK TO HOUSE SEWER $300 OVERFLOW SEEPAGE PIT DRAINFIELD Ix EXTN..CESSPOOL DRYWELL, $5 00 HWY OR ST WIDENING ALTER.REPAIR OR ABANDON HOUSE O SEWER OR DISPOSAL SYSTqM $300 STATE ENCROACHMENT W MANHOLE PERMIT NO. d 7.00 h INDUSTRIAL WASTE APPROVAL Z CHARGES Ow RAS PERMIT S 3 0 CONNECTION CHARGE PEE AUTHORIZATION TOTAL 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 S APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 2- qg 19� OWNER OR NEW HOUSE SEWER 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 LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER F, AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOV DESCR BED RES ENTI PROQERTY. ABANDON HOUSE SEW ER SIGNATURE / OFOF PERMfETEE�] BACKFI L SEPTIC TANKS ❑BACKFI L SEPTIC TANKS ❑ SPOOLS ❑ VALIDA'fI0 CK. M.O. CASH 10.0'0