HomeMy Public PortalAbout4824 GOLDEN WEST AVE_Sewer__ CEA042° APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING jPROCESS
ADDRESS �r�_OHN A. LANIBIE, CouatF EagmaerC SATT D. GRIFFIN, Supt of Building LOCALITY �NEARESTR APP ANT TO FILL IN ceosssr. ALEGALDESCRIPTION LOT NO. �1ti� OWNERMAIL
BLOCK TRACT ADDRESS4 �-SIZE OF LOT,*!-, Y /a NOW ON LOTNO.OF S CITY // �� TEL. N0. /��/JUSEOF fl + DISTRICT NO. GROUP MAP ED BY
BUILDINGS ,CIU ..,�� I 'BK PG I
CONTRACTOR
ADDRESS 9 �� �2" a_/ �JCONNECTION DATA
CITY TEL.N0. J 7 STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. ® COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
PUBLICS EWERCONNECTING TO @ $3.00
TYPE OF CONNECTION LEN T FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L. P.L.
PITS I""' ;^^^ @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 J CO.IMP.NO. Irl-NO.
CONNECT ADDITIONAL BLDG.OR TRUNKPERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00 •
SEWER'OR DISR
OSALSYSTEM HOUSE @ $100 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERNIIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEQTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS-DAY OF 19_ NEW HOUSE SEWER ��-7/l'�r�.
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD v,,.. "e ^+' +• ,,•F'_9.e__...,>._
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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
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 THE ABOVE
L
ESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS ❑
IGNATURE SEEP.PIT(S ❑ CESSPOOLS
OF PERMITTE - �
Ch. V LWATION ROBERT A. WOOD
CK. Y.o. CASH SUPERVISING MECHANICAL,ENGINEER
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0303130004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: SEWER / SEPTIC: X BUILDING ADDRESS:
ON FILE EXIST OCC GRP: 4838 GOLDEN WEST AV
BLDGS. NOW ON LOT: TEMP CA 917803935
ASSESSOR INFORMATION NUMBER: CONNECTION TYPE: NEAREST CROSS STREET: LOWER AZUSA
8589-020-025 ORIGINATION: THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
TENANT: MANHOLE REFERENCE: UPPER/LOWER: ISSUED ON: PROCESSED BY: EXPIRES ON:
COUNTY IMPROVEMENT NUMBER: 03/13/03 JK 09/09/03
OWNER: TEL. NO: PLAN CHECK NUMBER: FINAL DATE FINAL BY- CODE:
CHEUK NG AND MIA FANG WU (626) 286-3761- JOB NUMBER:
4838 GOLDEN WEST AV TRUNK PERMIT NUMBER:
Z'�
TEMP 917803935 ROAD PERMIT NUMBER: DESCRIPTION OF WORK
AFFADAVIT: NO CONNECT EXISTING HOUSE TO PUBLIC SEWER
WAIVER: NO
APPLICANT: TEL. NO: EASEMENT: NO
MLADEN GRBAVAC CONT CO (626) 355-1350-
P.O.BOX 660219 RECORD INSTRUMENT NBR: RECORD DATE: SPECIAL CONDITIONS:
ARCADIA 91006 HIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER: r
CONTRACTOR: TEL. NO: FEES PAID APPROVALS DATE INSPECTOR SIGNATURE
MLADEN GRBAVAC (626) 355-1350-
1235 RAMONA ROAD LIC. NO FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: NEW HOUSE SEWER
P.O. BOX 150 NONE
ARCADIA, CA 91006 01 PERMIT ISSUANCE FEE 27.75 CONNECT ADDITIONAL
03 CONN TO PUBLIC SEWER 1.00 CON 46.95 BUILDING OR WORK
ARCHITECT OR ENGINEER: TEL. N0: TOTAL FEES 74.70
SEPTIC TANK, SEEPAGE PIT
LIC. NO: AND/OR DRAIN FIELD
DRYWELL
SEWER MAP BOOK: PAGE: ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS _
SEEP. PIT CESSPOOL
GRAYWATER SYSTEM
REPORT ID: DPR266 ROUTE TO BS0508