HomeMy Public PortalAbout4844 GOLDEN WEST AVE_Sewer__ 76A642 D-61 APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS T /��!'�✓ �Y j
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST / %
FOR APPLICANT TO M IN CROSS ST. Q
LEGAL 1
DESCRIPTION LOT NO. OWNER C � /
BLOCK TRACT �, ' MAIL � ! /
ADDRESS G� �✓l V� !✓ rf'
77_/ N0.OF B DGS.
SIZE OF LOT v7..�L NOW ON LOT / CITY YG.-ci i L TEL. NO. T'L
USE OF
BUILDINGS P A,- - BK PG DISTRICT NO. GROUP MAP CESSED BY
�
CONTRACTOR If y -`>/1/ A
ADDRESS / 1/— aLi��/ rc� CONNECTION DATA
CITY y-C TEL.NO. 717 STATION DEPTH
STATE MANHOLE REFER CE UPPER
ltfREGISTRATION N0. C - I / l COUNTY LOWER
NO. 1 DESCRIPTION OF _ RK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNEC ON LE04TH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. .TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD }
EXTN..CESSPOOL. DRYWELL @ $2.00 0
HOUSE SEWER CONNECTING TO �^ P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 1 CO.IMP. N0. A JOB NO. U
WORK C H ADDITIONALUSE BLDG.OR @ $1 00 TRUNK PERMIT NO. AD PERMIT NO. O
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHME (—
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. V
W
INDUSTRIAL a
WASTE APPR AL N
CHARGES z
OWNER'S
ER'S PERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 4f-e- REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUI LDING OR'WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1S 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGL OWNER OF THE ABOVE SEPT ❑
DESCRIBED RESIDENTIAL P PERTjY,"��~ BACK FILL
/ SEEP.PIT(S ❑IC CESTANKSSPOOLS
SIGNATURE
OF PERMITTE
ATION ROBERT A. WOOD
c6. w.o. CASH SUPERVISING MECHANICAL ENGINEER
L :a, 6S) 521-0 L3111. 1 � U 6.00 v"
+ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0303130OD7
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-DM EXT:
LEGAL ID' SEWER X ERJILDING ADDRESS:
� I
ON FILE EXIST OCC GRP::
4844 GOLDEN WEST AV
BLDGS. NOW ON LOT: TEMP CA 917803935
ASSESSOR INFOR14ATION NUMBER: CONNECTION TYPE: NEAREST CROSS STREET: LOWER AZUSA
8589-020-022 ORIGINATION: THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
MANHOLE REFERENCE: UPPER/LOWER: •
COLMTY IMPROVBIF]iT NlMiBER: 03/13/03 JK 09/09/03
OWNER: TEL. NO: PLAN CHECK NUMBER: FINAL DATE FINAL BY: DME:
H" HUI MING LEE (626) 285-6437- JOB NUMBER:
4844 GOLDEN WEST AV TRUNK PERMIT NUMBER: 7-
T E14P
-TEMP 91780 ROAD PERMIT NUMBER
AFFADAVIT: NO CONNECT EXISTING HOUSE TO PUBLIC SEWER
WAIVER: NO
APPLICAKT- TEL. EASEMENT: NO
EN
MLADGRBAVAC CONT CO (626) 3551350-
P.O.BO)( 660219 RECORD INSTRUKEJWT MBR: RECORD DATE: SPECIAL COMITIONS:
ARCADIA 91D06 HIGHUAY/STREET WI,DBtING:_ ,
STATE ENCROACHMbiT-PERNIT GIMBER:
CONTRACTOR: TEL.-W rrt.*-PAID APPROVALS DATE INSPECTOR SIGNATLSM--
MLADEN GRSAVAC (626) 355-1350m -
1235 RAMONA ROAD LIC. NO FEg-,DES(;RlpTION: GUANTIT-Y UOM: AMOUNT: NEW HOUSE SEWR
P.O. BOX 150 NONE
ARCADIA, CA 91006 01 PE'I64IT I CE FEE27.75
03 cbkN TO�I>UB IO. S ` 1.00 CDN � 46.95 BUILDING OR WORK
. "_ _ TOTAL ,FEES \ " 74.70
SEPTIC
LIC. NO: i' �' AND/OR DRAIN FIELD
DRYWELL
�1
9 PAGE:
REPAIR SEWER OR
- - - - - -
' SM DISPOSI►L SYSTEM
DISCONNECT PLW��
ABANDON HOUSE SE6ER
BACKFILL 50TIC-rAXKF
SEEP. PIT CESSPOOL
GRAYWATER SYSTEM
REPORT ID: DPR266 ROUTE TO : B$0508
`^ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0303130006
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: 4842 GOLDEN WEST AV
BLDGS. NOW ON LOT: TEMP CA 917803935
ASSESSOR INFORMATION NUMBER: CONNECTION TYPE: NEAREST CROSS STREET: LOWER AZUSA
8589-020-023 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:
RICHARD SU (626) 285-5421- JOB NUMBER: '���-p 3
4842 GOLDEN WEST AV TRUNK PERMIT NUMBER:
TEMP 91780 ROAD PERMIT NUMBER: DESCRIPTION OF WORK
AFFADAVIT: NO CONNECT EXISTING HOUSE TO PUBLIC SEWER
WAIVER: NO
APPLICANT: TEL. N0: 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:
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