HomeMy Public PortalAbout4851 GOLDEN WEST AVE_Sewer__ DEPAIVrA FaW OF OOUNTY ]ENGINEER SEWER-SEWAGE DISPOSAL 1
Dn9ISION OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNTY OF IAS ANGIn.E�
WILLIAM J. FOX, COuHTY ENaIN[[R BUILDING
ADDRESS
FOR N ` LOCALITY
BUILDINGQ
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ADDRE88 t d..c' j`� Croon ST.
LOCALITY !' DIST RI NC. $[t1AL No. PEBEIT M0.
NEAREST
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CR088 ST.
RE; IY Rswhr fr� DATEISSUED
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PAIL
ADDRESS US[ZONE OCOUPAMOY AP Y
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CONTRACTOR yy-�
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ADDRESS
'= JOE M0.
CI TEL NO. TRUNK PERMIT NO.
STATE
REBIBTRA ON N0. COUNTY ROAD PERMIT M0.
LEGAL STATE ENCROACHMENT
DElZCRIPTION LOT M0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT M0.OF BLOM
NOW ON LOT CHARGES
USE OF
BUILDINGS OONMEOTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIO SEWER 0 3-51 RECEIPT M0. DATE BY
AbLfir SEWER oCmNECTIme To
PRIVATE DISPOSAL SYSTEM IA9
GONNECY ADDITIONAL BL S.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER I."
A LT ER 0R REPAIR ING NO. DATE BY
SEWER OR DISPOSAL SYSTEM 1.09
DISCONNECT AND ABANDON SEWER
AMD OR DISPOSAL SYSTEM Les CONNEdTION DATA
TANK,8 R
PIT$AMD OR DRAINFIELD 2A0 STATION DEPTH
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY l.Et MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS Pamrr ; 1 00 Y. CURB P.L. M.L TO P.L.
AUfHORRAIION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HER-KIN NAMED
CONTRACTOR TO CONMECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPEOTO"SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NIEW HOUSE SEWER
OWNER OR BBUIILDI G ORNECT DWORKAL /d IV ,
OWNERS AGENT f
SEPTIC TANK SEEP.PIT($)
ADDRIESS AMD OG DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL F]CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTERR,,REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPO>3AL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AMD%R LIOENSED AS REQUIRED BY LOS ANGELES COUNTY
AMD STATE OF CAUFORMIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED WSIDENTIA ROPERTY. ILL SEPTIOTAM KS BJBNATURE ❑
fEEP.PIT(S)EI CESSPOOL/[-]
OF PERMITT[
T A m 6Q7 I/67
J
4
CES00 2/70 APPLICATION FOR PERMIT
78A 6421)
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DE;ART INT OF COUNTY ENGINEER
UILDI d AND SAFETY DIVISION 7ADDREAS
JOHN A. LAMBIE, COUNTY ENGINKFR .�/ (rCGOFy4/ a-JLSCOLEMAN W. JENKINS. SUST. of BUILDINGLM L C t T
TO ILL IN w c�S
(PRINT OR TY E ONLY) 7
DESCRIPTION LOT NO. OWNER R. R =� Al
y� 1
MAIL T
BLOCK TRACT y� ADDRESS y � .dw arc 7'
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT I CITY it Mr TEL NO.
USE OFaa
■U ILDINGS V-0 • DISTRICT NO. GROUP CLADS MAP FROG[IBES SY
OK ps
CONTRACTOR Q,.Lit I -f
ADDRESS 404;32, CIEQV3 AUX-r CO CTION D TA
CITY (�1(1/- ��]IrILTEL. HO. �1 p�� .� STATION DEPTH
STATE NO,, �,a��{7�{ LIC
ES Com( Q� MANHOLE R[FER[NCE UPPER
Cd-Ad1600111111P
No. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LKN0rH F oM
HOUSE SEWER CONN[CTINO TO Y. CURB P. M.L TO P.
PUBLIC S[WIR P.C.NO. f 310
PTIC TANK.S [P GE FI OR JOB NO.
PITS AND/OR DRAINFI[LD SIO.00 CO.IMP.NO.
HOUSE SEWER CONN[CTINO TO TRUNK PERMIT NO. ROAD PERMrT ISO.
PRIVATE DISPOSAL SYSTEM 57.00 D.
CONNECT ADDITIONAL SLDa.OR AFFIDAVIT I BAIRI I'[A/ES[IfT RECORD.INS".NO. DAT[ O
WORK TO HOUSE SEWER 17.00 IJ
OVERFLOW SEEPAGE PTT.DRAINFIELD Ckd
E%TN..CESSPOOL.DRYWELLMANNOLE 90.00
A,LY 11 R,R KPAIR OR ABA D m6ust HWY.OR ST.WIDENING 101�
SEWER OR DISPOSAL SYSTEM 99.00 STAT[K.NCROACHMKP4TlJ
PERMIT NO. IIILLLL
CL
INDUSTRIAL
WASTE APPROVAL
OWNESOH '3 �T s ('oCHARGE, —
AIITHTLATION TOTAL FEF /01 /QV CONNECTION CHARGE FEE
IHAV[ AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON- REIMBURS[M[NT FEE
TRACTOR TO CONNECT T14[ ABOVE D[fCRIBID E%SETING DWEL LINO A OVA1�
TO THE PUBLIC 1 IN CTO 'f-'-NATURE
SIGNED THIB [R. DAY OF N 162L
OWNER OR NEW HOUSE SEWER S�
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SID-TIC TANK,BEET,PITS)
I H[R[EY ACKNOWLEDGE THAT I HAVE READ THIB APPLICATION AND/OR DRAINFI[LD
AND 'TAT[ THAT THE ABOVE 10 CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAW- REGULATING
PLUMBING AND SEW[RS. CESSPOOL ElDRYW[LL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICRNS[D AS REOUIR[D ■Y LOB ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYfT�M
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
R[BI D[ IN, THE ABOVE DESCRIBED RESIPKNTIAL PROPERTY. ABANDON HOUSE BOWER
SIGNAOF TUPlCMTTTQ �/ L RE SACKFILL IC TANKS
fEEP.PrT(B) ❑ Cwroou y
AIMATION JACK R. ALLKN
SUPERVFMING MECHANICAL ENGINEER
CK. M.O. CASH
d 0;j XlN 4 1 0 D 1 0.00- IT