HomeMy Public PortalAbout9235 KEY WEST ST_Sewer__ i
0A642D°.62
7APPLICATION FOR PERMIT
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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 CROrS ST +
LEGAL
DESCRIPTION LOT NO OWNER
Li MAIL
BLOCK TRACT , ADDRESS G')Las
NO OF SLOGS .T t
SIZE OF LOT Jrf NOW ON LOT CITY _1_w s4 i�. TEL NO
USE OF
BUILDINGS J'� DISTRICT NO GROUP MAP �YfiDCE55ED BY
yJ BK PG
CONTRACTOR 5 /�
ADDRESS a CONNECTION DATA
,/p STATION DEPTH
CITY TEL NO D
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE CONNECTION LENGTH FROM d
HOUSE SEWER CONNECTING TO Y C B PL M L TO P L O
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR CO I NO JOB NO U
PITS ANOR DRAINFIELD @ $1000 Ix
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROADZRI
O
PRIVATE DISPOSAL SYSTEM @ $300 F-.
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER IASEMENT RECORD DATE W
WORK TO HOUSE SEWER @ $300 d
OVERFLOW SEEPAGE PIT DRAINFIELD to
EXTN CESSPOOL DRYWELL MANHOLE @ S500 Z
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SY TEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTI CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REII,I URSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF -19-
OWNER
9OWNER 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 IAM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT-1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE D CRIED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S)
❑ CESSPOOLS ❑
CK yALIDATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
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