HomeMy Public PortalAbout9837 KEY WEST ST_Sewer__ 68�'g gBAeaaDx36 APPLICATION FOR PERMIT 1
Lam.Y- 3
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of LOB Angeles B U'ADD DIrNG
WM.J. FOX,COUNTY ENGINEER
f CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALIT
J/ T
FOR APPLICANT TO FILL IN NEAREST
LEGL
CROSS ST
DESCRIPTION LOT NO />,V / r�L/�; OWNER L D
BLOCK TRACT MAIL
ADDRESS G�
NO OF BLDGS
SIZE OF LOT NOW ON LOT CIT _�' TEL. NO -�
USE OF
BUILDINGS :MANHOLE
I GROUP MAP
BK :j:_
CONTRACTOR Gy /� S 9G
ADDRESS CONNECTION DATA
r�
CITY TEL NO DEPTH
❑ STATE EN E UPPER
REGISTRATION NO ❑ COUNTY ` LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FPONI
Y CURB P L M L TOP L
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP N JOB NCI
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERM NO ROADRMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCRO" HMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD -300 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL _
SPECIAL CONDITIONS ONLY 2 00 CHARGES
$ 1 00
OWNER'S
PERMIT CONNECT CHARGE E
,
AUTHORIZATION I TOTAL FEE R BURSEMENT FEE
IHAVE MED CON'
TRACTORTOCONNECT DATE O THE AABOVE CTED WDESCRIBED EXISITH THE TING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19- NEW HOUSE SEWER A
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD _
IO ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑,DRYWELL[IAND STATE THAT THE ABOVE IS 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 AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWEP
DESCRIBED RESIDE AL PROPERTY, ` BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTE
WILLIAM J. OX, OUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
�Co 8 0 3 3 JUL 12 4 2.0 0 If)