HomeMy Public PortalAbout4923 GOLDEN WEST AVE_Sewer__ APPLICATION FOR PERMIT ' 1
COUNTY OF Los ARCUM SEWERAGE DISPOSAL
DEBAHTMENT of couNTT ENS
BDII.DIZf Ci AND SAFETY DMSI ON B U 1 LD I N G .
JOMff A.CAMUM Tt� � Ham ADDRESS
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FOR APPLI O FILL IN caoXEA
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DESCRIPTION LAT#O OINEII
BLOCK TRACT MAIL
ADDREW
X0.OF BLDOS.
SIZE OF LOT X07 OX LOT CFYT 77KL.NO.
USE OF
B GS DISTRICT X0. GROUP [AP
COXTRACTO _ j-) DC A
ADDR �(? �J COHN>E OZf DATA
CITY TEL I10, - STATI014 DRPTH
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REGISTRATION N0. "7 n MAX H0 LE CE U I" COUNTY
No. DES4;R]FrTION OF WORKFEE
HOUSE SEWER COXN CTIXG TO
PUBLIC SEWER 0 4 3.tV _ '�H
SEPTIC'ff�111K,SEEPAGE PIT OR T TYPE OF CONXCURBECTIONP.L L- PFRLOM 3
PITS AND/OR DRAINFIELD 5.00
OVtPFLOW SV.V-PAGt PIT,DRAIXFIELD
EKTX. CSSSp00 DRTWELL MANHOLE 2.00
HOUSE SEWER CONNECTING TO JO.
PRIVATE DISPOSAL SYSTEM 1.00 CO.IMP.XO. 1-3 dOBB XO
CONNECT ADDITIONAL BLDG.OR -
4 KORA TO HOUSE SEWER 1.00 TRUNK PERMIT X0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM 1.00 STATE ENCROACHIENT
PERMIT NO.
_ _ _INDUSTRIAL
_ tASfE APPROVA
CHARGES
OSS PEMT
A00 CONNHcnOM cH"GE Ftp
AUTSORMTION "Y{}TAL FELf - - ('7' Rill■BURSEMEXT FEE -
1 HAVE AT THIS DDAT9 A CONTRACT W4TH THE HEREIN MA-RIM-COM.
TRACTORTO CONVECT THE ABOVE DESCRIBED EZISTIXG DWELLING, AMOVAIS TE 1XSPECTOB'38IGNATURE
TO THE PUBLIC IUL
SIGNED THIS AY OF -- - 19 NEW HOUSE SEWER
OWNER OR - -- - - - -CONNECT ADDITIONAL - - -
OWNERS AIfT BUILDING OR WORK
ADDOES - -" - 86PTIC TAN[ SEEP,PIk(a)
API OR�DRAIXFIEm _
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOYE IS CORRECT AND AGREE TO COYPU CESSPOOL U DRTWELLJJ -- - - -
VM ALL -COUNTY ORDINANCES AXD STATZ LAWS REGULATING
PLUMBING AXD l EVERS. ALTER.REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM -PROPERLT-REGISTERED ANDlOR SMAGE DISPOSAL SYSTEM - - - - -
LICENSED AS REQUIRED BY LAS ANGETFS COUNTY AND ATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I lI44� E AAAPIDON HOUSE SEWER _
DESCRIBED YEOjD pRb OF T �� BACKFILL TAN[p 11
SIGNATURE SEEP.PIT S CEBSPOOLs
OF PERP
e' V ALIDATION _ROBERT-A. -WOOID --
X,o. can JIUPYRVISIFId YYC1-IArllr.i ENOINB:tLR
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