HomeMy Public PortalAbout4901 GOLDEN WEST AVE_Sewer__ 764-642D - CE606 - 9/73 APPLICATION FOR PER IT
COUNTY OF'LOs ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING v , (3�7 {�
ADDREYS 4 1 No oldm aut Ave.
mTemple Cij.ta
FD
R APPLICANT TO FILL IN NIARErT La Rosa
CRO.,-ST.
ION LOT NO. OW11[Ragpdy Ha"
MAIL
TRACT 3 ADDA Me �y e� �
OT NOW ONBLLU'T. CITY fy. TO_ NO. 287-3372
DISTRICT N0. ROUP MAP 1[D ■Y
Inc. ( /_ OR yr 7S
OR Own Bros• Inv /D9f4265 >1QmCTIox nAr L
STATION DEPTH
Mr 8Tla. XO. 0078
/1STATKNO. 231 J 41 �CL,AIC M v MANHOLE OL!Rg[R[NCI LOvm„
No. DESCRIPTION OF WORK FII TYPE OF CONNECTION LKNO-TH FROM
rIj SE B[W;R CONN[CT1MG To . ;7 00 Y. Cy R■ P.L M.L YO F.L
BIYy� P.d.NO.
Ski-Tic i AGE PIT OR CQ.IMF.NO. JOB NO.
PITS AND/Oh DRAINFIELQ 510.00
pU■ SEW"CONNECTING TO TRUNK PERMIT NO. ROAD P<11MIT NO.
PRIVATE DISPOSAL SYSTEM • 52.00
CONNECT ADDITIONAL BLDG.ORAFFIDAVIT I WUY[7 I EAJBII[BT RLCORD.INSTR.NO. DATE
WORK TO'HOUSE 99WIR • iS.OD
OVERFLOW SLIPAgI PIT.DRAINil"
IXrN..CES POOLORYWtLL_ 0 •6.00
AL AIR OR ARAND014 HWY.OR ST.WIDENING
TWjt'SEWER OR DISPOSAL SYSTEM HOUSE � 7.00 STATE KNCROACHM
MANHOLE . $7.0Q .PERMIT NO.
INDUSTRIAL C�
WASTE APPROVAL y
O E S �r • Ram C
S11
CONNECTION CHARGR FIE --
AUTHORIZATION ToTiLL FEE
I HAVE AT THS■ DATE A CONTRACT WFTH THL RKR[IN NAID CON- REIMBU Il"M[NT -
TRACTOR TO CONNECT THE ABOVE DEICRIMM ING
TO THE PUBLIC SEWER. APPROVALS DATE INAP[CTOR'S SIGNATURE
BIGNED THIS DAY OF 19_
OWNER OR NEW ROWS[B[WIA
OWNERS AGENT CONNECTADDITIONAL ��I
BUILDING OR WORK JPS`""
ADDRRSS SEPTIC TANK,S[Q,P4T(1)
I. HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELb
AND STAT[ THAT THEASQV[ 10 CORRECT AND AGR[I TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATS LAWS R[SULATING CESSPOOL Cl DRILL ElYW
PLUMBING AND SEW tRi.
I HERESY CF TIFY THAT i AM PROPERLY REGISTERED AND/QR ALTER,REPAIR.SEWER OIC
LIC EN SLD AS REQUIRED BY LOS ANGLES COUNTY AND IITAT[ OF SEWAGE DISPOdLALAFYSTEM
CALIFORNIA OR TH I A .THE LEGAL OWNER OF, AND INT`KKD TO DISCONNECT PLUG AND
R[11D[ (N, l`H[ ♦ RIBID R IAL PRO P[RTY. ABANDON WOUBE SEWER
SIGNATURE BACKFILL SEPT LINKS ❑
OF PAISIT
RATE[ SEEP.PITS) LJ CESSPOOLS
vAmbAvICIN CE. M.0, CASH
9.00 ' . .
V�
7&k542D f
r=,
CEQOS a-0e APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPO AL
DM?ARTHENT OF COUNTY ENGINEM
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMBiE, Count= En��ia�eol ADDRESS
COLEMAN W. JENUNS,Sup I. o(Bolldin6
LOCALITY
NEARB-ST
FOR .APMC TO FILL CROSS T.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
O. OF SILD125.
SIZE OF LOT NOW ON LOT CITY T[L. NO.
USE OF
■Y
BUILDINGS DISTRICT NO. GROUP BK MAP FROG
"o - g 1
CONTRACTOR
ADDRESS CONNECTION DATA
CITY T[L. NO.
STATION DEFTH
LICENSE /17 LICE NS! /n, _ UFF[!t
NO. V CLASS e/ MANHOLE R[F[R[NC[ /
N SCRIPTIQN OF WORK FEE P[OF CONNECTION
HOUSE [EWER CONNECTING TO Y. CURB P.L_ M.L.TO F.L
PUBLIC SEWER ! $ 5.00
ANK, SEEPAGE PIT OR
I�3D� P.C.NO.
PITS AND/OR DRAINFI[LD f *10.00 CO.IMP, NO. JOS NO.
HOUSE SEWER CONNCCTING TO TRUNK P"MIT NO. ROAD PER)d TT K / /
PRIVATE DISPOSAL SYSTEM S S 9.00 A
CONWFCT M.A AFFIDAVIT •AIV[, w[GlR RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER f $ 9.00
ALTER. REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM f $ 9.00
HWY. OR ST.WIDENING
[XT N.,CESSPOOL, MANHOLE • ; 6.00 STATE ENCROACHMENT
PERCOLATION TEST f $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APFROVAL
OWNERS PERMIT i 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'1 HAVK AT THIS DAT[ A CONTRACT WITH THE H[R[IN M<D CON-
REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ASOVE D[SCRISED L?UfTING DWELLING
TO THE PUBLIC S[W[R. AIT$OVAT Q DATE INfP[CTOR'd SIGNATURE
SIGNED THIS DAY OR 18_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADD TiIONAL
ADDRESS
BUILDING OR WORK
BEFTIC TANK,SEEP.FIT(B)
I HEREBY ACKNOWLEDOK THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STAT[ THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STAT[ LAWS R[GULATINO C[BS POOL ❑ DREW=LL ❑
FLU MIS 1140 E
O AND SWERS.
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES S [COUNTY AND TATOF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGA ER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE /ISO ESC Tl OP[RTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE AmA BACKFILL SErhC TANKS ❑
SEEP,PITS) U CEI.SPOOLB
cCK. AMATION
M.O. CASH
Log-7 4 9�8 X10 1 0 0 7.00,, 4
I
eeeoe a-ee
7eAe42D APPLICATION FOR PERMI
COUNTY OF IAS ANGELES SEWER—SEWAGE DISOSAL
DtPARrM$NT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION euILDINo
JOAN A.LAMBIE, County Enngi�Lnneer ADDR�
COLEMAN A. JENKINS,Sap t. of Building
L OCA L TTY
NEAREST
FOR APPLICANT TO FILL IN CROs6 eT.
•
DESCRIPTION LOT'N O. OWNER
MAIL
BLOCK TRACT AQDIRESE
NO. OF OLD00.
SIZE OP LOT NOW ON LOT CF7Y \ [ TEL: NO. '4'C"ejFL/ 4e
USE OF DISTRICT NO. ORp MAR R 11,11,■U ILDINGS
■K P
J�
CONTMCTOR
ADDRESS CONNECTION DAT
STAT10 DEPTH
C FTY TEL. NO.
LIC[ DE LIC[NSIE
NO. C-LASS MANHOL,K R[P[ G[
LOW;R
No. DESCRIPTION OF WORK FE[ TYPE OR CONN[ LIa7
H%8ff SEWER CONNECTINS TO Y. CURS
L. MIL .L,
PUC LIC SEWER 0 3 15.00 P
PITS AND/OR DRAINEIELD 0 $10.00 CO.INR.NO. NA•
HOUSE SEWER CONNSCTIN& TO TRUNK PERMIT NO. ROAD 17T NO.
PIIJVATE DFS POSAL SYSTEM -0 $ 3.00
CONNICT AFTIDAVIT Sint■ [*T RECORD.INeTR.N . DATL
WORD TO HOUSE SEWER I 3.00
SEWER Op AIRDISROSAL SYSTEM & f 3.00
PIT, 0
RWM'. WIDENING
ERTN.,CESSPOOL, MANYOLE 0 $ 5.00 T£ENCROAC•HM[NT
PERCOLATION TEST S $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHAIR
OVVNER'S PERMIT s 2 00 cHH ,
CONNECTION CHARGE F[[ V
AUTHORIZATION TorAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT F[[
TRACTOR TO CONNECT TFIE•ASOVE DESCRE
IBD LXIITJNO DWELLING IIO♦ 'S SI
TO THE PUSLIC SEWER. DAT; INSPECTORGNATURE
SIGN-ED THIS Y OR 1$
OWNER OR ' NEW HOUSE sKw4m
OW N[!tY AO[NT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
o EPTIC TANR.SEEP,PIT(&)
IH
ACKNOWL[DOE T+JAT J HAVE READ THIS APPLICATION AND/OR DRAYNFIELD
AND STAT[ THAT THE ABOVE le CORRECT ANq AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REOULATING CESSPOOL ❑ DRYW[LL ❑
LHIERXBY
AND SEWERS.
-CERTIFY THAT I AM PRO"RLY REGISTEIt[D AND/DR ALTER,REPAIR,SEWER OR
AS REQUIRED BYLOS ANGLES COUNTY ANq &TATE OF miEWAOE DISPOSAL SYSTEM
A OR THAT I AM'THt LJ[OAL OWNER OF, AN NT;ND TOAND
, THE A60 9 RI■ n[eIq NTIA� PA DISCONNECT PLUG WEAeAN DON HOUS[SEW[R
ITTEt BACKFILL SEPIF TAN" ❑
S[[P,FTT(S) L� C[SSPOOLJ
)fAMATIQN
�?4 CK. M.0. CASH
3 x 1 2 40.00 3