HomeMy Public PortalAbout9823 KEY WEST ST_Sewer__ 746421)
CE 809(REV 6,781
APPLICATION.FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY '
FOR APPLICANT TO FILL IN DISTRICT NO GROUP MAP CES D V
RK� Z
BUILDING
ADDRESS
LOCALITY
CONNECTION DATA
_
NEAREST STATION DEPTH
CROSS ST
UPPER �
MANHOLE REFERENCE LOWER
OWNER '� TYPE OF CONNECTION LENGTH FROM
MAIL Y CURB PL ML TO PL
ADDRESS
- PC NO � '
^r -
CITU NO
CO IMP NO JOB NO
L «cB
LEGAL TRUNK PERMIT NO ROAD PERMIT NO
DESCRIPTION LOT NO '
BLOCK TRACT ER EASEMENT R
AFFIDAVIT WAIVECORD INSTR NOT DATE
NO OF BLDGS
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
USE OF
BUILDINGS ` STATE ENCROACHMENT
PERMIT NO
LZ INDUSTRIAL
/�J�/�
CONTRACTOR
/J F WASTE APPROVAL
ADDRESS �yj�p X l ,6�J ` CONNECTION CHARGE FEE CHARGES
CITY J�/�,,///�� p
NG� Gla / TEL NO f+�G'r
STATE LIC REIMBURSEMENT FEE
LICENSE NO J CLAS
NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER,
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK ,4a/i ce ATL
PRIVATE DISPOSAL SYSTEM y
SANA,SEEP.PITIS)
CONNECT ADDITIONAL BLDG OR AND/OR
DRAINFIELD
WORK TO HOUSE SEWER o
OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN CESSPOOL,DRYWELL,MANHOLE
LTE EPAIR OR ABANDON HOUSE ALTER REPAIR.SEWER OR
R OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND - � - •
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ •- 1
OWNER'S
Perm it S SEEP,PIT(S)❑ CESSPOOLS❑
AUTHORIZATION TOTAL FEE' VALIDATION'
I HAVE T ,CO DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTORRTOOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER
SIGNED THIS DAY OF 19_ 947x1 A - •�
OWNEROR
OWNERS AGENT-
.} ..di O O. O O 10 ,.
ADDRESS ff
I-HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 2 O - 1 4,00
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS O.O O y,O O
M •"
I HEREBY CERTIFY THAT I AM PROP EGISTERED AND/OR
LICENSED AS REUiEDE
UIRED LOS ANGE ES CO TY AND,STATE OF
CALIFORNIA OR ATI T E LEGAL O ER OF, NO INTEND TO RE- A 60,6
--7-9-
S
,7 O.
SIDE IN THE CRIBED RESIDEN L PR ERTY _ U J
SIGNATURE - ^•
OF PE RMITTE