HomeMy Public PortalAbout4855 GOLDEN WEST AVE_Sewer__ -61
76A6423-61
APPLICATION FOR PERMIT 1� �
76A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESSG
JOHN A. LAMBIE, County Engineer
WILLIAM A. IENSEN. Supt of Building LOCALITY
NEAREST <
FOR APPLICANT TO FILL IN CROSS ST.LEAL
1
DESCRIPTION LOT NO. OWNER ./ 1 -ft
BLOCK TRACT E �� MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS +�-s_� DISTRICT NO. GROUP MAP P ESSED BY
BK PG ,
CONTRACTOR
ADDRESS � p CONNECTION DATA
STATION DEPTH
CITY �. TEL.N0. ,�
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. 3 B COUNTY LOWER
NO. DESCRIPTION OF R FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CON ECTION LENGTH FROM
PITS AND/OR DRAINFGIELDIT OR @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00 d
HOUSE SEWER CONNECTING TO P.C.NO��% O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. PERMIT NO. O
WORK TO HOUSE SEWER - $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT F
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. U
W
INE
NDUSTRIAL C_
WASTE APPROVAC�/' to
,iT7�T CHARGES z
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEREIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCEXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF19 NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERS AGENTBUILDING OR WORK
ADDRESSSEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HATHIS APPLICATION
AND STATE THAT THE ABOVE IS CDRREAGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES ANDLAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROEGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGENTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGER OF THE ABOVEDESCRIBED RESIDENAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURESEEP.PITS) ❑ CESSPOOLS
OF PERMITTE -
�VAL ROBERT WOOD
CK./ Y..0.0. CASH SUPERVISING MECHANICAL ENGINEER
LC0577 DEC 61 p 6.0 p
�t
CE808 Z/70 APPLICATION FOR PERMIT
7eA e4zD
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FjNFA�REVT
DING
JOHN A. LAMSIE, COUNTY ENGINEER RESS J�SJ V VLOB G.7 QST
COLEMAN W. JENKINS. SUPT. OF BUILDING
LITY `TtMP� C-f Z'
APPLICANT O FILL IN SST. LovLICZv1
(PRINT OR TYPE ONLY)
DESCRIPTION LOT NO. OWNER L� L• N�
MAIL
BLOCK TRACT AD DRlJI y�r ' O �' p NW 19,67'
N OF RLDO■.
BIZ[ OF LOT HOW ON LOT CITY M t4ry TIL NO.
Uf[ OF
■UILDINOS W�n DIETR/IIC •
TKO. ROUP CLAS[ MAP PROCESSED BY
V f Y eR FE /n7
CONTRACTOR .Wl 4LCaNtiT. ( �/
ADDRESS J04,32, (2dt"g 14 Via- COHIfEC'rION T11t
/TATI ON
crTY &Wr ,&; TIL. No. 4�� •�
STATE .I UPPER
LICENSE NO, 'j;�.Aft LCi.A fS L /r MANHOLE R[FERINC[
NO. I D"CRIPTION OF WORK FIE TYPE OF G`ONNECTION LIENOT ROM
HOUSE SEWER CONNECTING TO Y. CURB P.L M.L.T
P ■LIC SEWER P.C.NO-
• PTI M SE[PAGI1 PI OR CO.IMP.NO. JOB NO.
PITS AHD/OR DRAIMF[[LID 510.00
HOU■[S[WR COryH[CTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $9.0.0 O
CONNECT ADDITIONAL O.OR AFFIDAVIT SAMN IYOIEST RECORD.IN97R.NO. DAfI V
WORK TO HOUSE■EWER E3.00
OVERFLOW SI[PAO[PIT.DRAINFIELD D1
K)TN..C[SSPOOLDRYWRLMANHOL[ SB.00 HWY.OR R.WIDENING O
AL R PAIR ORA DON ROU■
SI W[R OR DISPOSAL/YST[M f3.00 STAT[INCRO CHM[NT
PERMIT NO. d
INDUSTRIAL
,■}'E}�p WAST[APPROVAL Z_
O^1\LII�� HMIr s 00
CHARGES
CONNECTION CHARGE"a
AOTHOffiZATION TOTAL FEE
I HAVE AT TNI■ DATE A CONTRACT WITH THE HEREIN NAMED CON-
REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE D[SCRISED E%IfTING DWELLING
TO THE PUBLIC qjt%-[R. APPROVALS DATE INfP[CTOR'f SIGNATURE
SIGNED THIG - LLP DAY OF, L) 'A Al —l'-12-
OWNER
p7ZOWNER OR NSW HOUSE SEWER T
OWNER■AGENT CONNECT ADDITIONAL
ADDRUf BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(9)
1 H[R[BY ACKNOW LEDt7[ THAT I HAVE R[AD THIS APPLICATION AND/OR DRAINFIELD
AND •TAT[ THAT TH[ AeQV[ If CORRECT AND AGR[[ TO COMPLY
WfTH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMMING AND SEWERS. ci/SPOOL ❑ DRYW[LL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERm AHD/OR ALTER.REPAIR.BLEW"OR _
LIC[NS[D A■ REQUIRED BY LOS ANG 'COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LSGAL OLE/WNER OF, AND INTEND TO DISCONNECT PLUO'AND
RESIDE IN, THE ABOVE DESCRIBED RESID[KTIAL PROPERTY,
�nJ ABANDON NOUS[SEWERSIGNATURE
OF PERMTTT[E 11 Ialt tC AW_" . _ SACKFILL S[PLC TANK/ ❑
CKAGPOOLS
ATION JA R. ALLCN
cK M.0' CASH SUPERVISING MECHANICAL ENGINEER
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