HomeMy Public PortalAbout9855 KEY WEST ST_Sewer__ t
F808-D
CAPPLICATION FOR PERMIT .
_
eaos.e•se COUNTY OF LOS ANGELES
' SEWER—SEWAGF DISPOSAL ,
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION BUILDING
JOHN A. LAMIE County gineer En ADDRESS
CASSATT D. GBIF'FIN, Sup't of Building LOCALITY
NEAREST ,
FOR APPLICANT TO FILL IN CROSS ST
LEGAL t '1
DESCRIPTION LOT NOOWNER
`—
BLOCK TRACT MAIL ADDRESS'
NO Off BLDGS. '.
SIZE OF LOT NOW ON LOT CIT TEL
USE OF
BUILDINGS DISTRICT'NO ROUP MAP PROCESSED BY
K PG
CONTRACTOR
t T1s t �6
ADDRESS L3 ' CONNECT14 DATA
CITY f TEL.N0. D STATION � grEPTH
,Q �YSTATE MANHOLE REFERENCE
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REGISTRATION NO ❑ COUNTY - I LOWER
No I DESCRIPTION OF VORK FEE
HOUSE SEWER CONNECTING TO 'a "
PUBLIC SEWER @ $3.00 r�/
SEPTIC TANK, SEEPAGE PIT OR TYPE OF- TION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3'00 Y. CURB P L. M L TO P L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P.C. NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO ROAD PERMIT NO
ON
ALTER, REPAIR DISPOSAL SYSTEM HOUSE �'$1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -REIMBURSEMENT FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DTE INSP
TRACTOR TO CONNECT THE ABOVE DE IBED E ACTOR'S SIGNATURE
STING DWELLING Ei
TO THE PUBLIC SE s J p
'SIGNED THIS Q A'Yj �"" Ig NEW HOUSE SEWER __-
OWNER OR a CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK"
SEPTICTANK,•SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE-THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO'COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND ,
LICENSED AS REQUIRED BY LOS ANGELES-COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF HE �BOYE
DESCRIBED,RES E� PRi'? 1 BACKFILL SEPTIC TANKS❑ 7
SIGNATURE SEEP PIT(s) ElCESSPOOLS GJ T
OF PERMITT , _
®r VALIDATIOI' ROBERT A WOOD
CK H o. \!CASH' _ SUPERVISING MECHANICAL ENGINEER
L r a 9 0 ,tUL 21,Q 4 r, 5,C) 0