HomeMy Public PortalAbout4928 GOLDEN WEST AVE_Sewer__ DEPAWrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTYLOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING e!4:az v
ADDRESS ,�
FOR APPLICANT TO FILL IN LOCALITY
BUILDINGNEARE8T
ADDRESS ' J�yd���.y mares CROSS ST.
LOCALITY �� /� DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST / L1 gaf A ----� I J
CROSS ST. j `I-j w RE Ready B_0"" Ready for Inspection 1-4 74,,r
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OWNER =��iLI�/� G /`�/��`• b`'e�*+,��.�'� /j
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ADDRESS C/l�f a —Pj }� /� ` Pyr
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ADDRESS
DRESS
JOB N0.
CITY TELAO. TRUNK PERMIT NO.
[][jCOUNTY ROAD PERMIT N0.STATE 2 7 3
REGISTRATION N0.
LEGAL STATE ENCROACHMENT-
DESCRIPTION LOT NO. PERMIT NO.
BLOCK -- TRACT Iy40 d INDUSTRIAL
SIZE OF LOT s� /x NO.OF BLOCS. WASTE APPROVAL
, �Is NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE E
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50J RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PR:VATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EX PTI I RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO TE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION
CESSPOOL—DRYWELL f DEPTH
SPECIAL CONDITIONS ONLY 2.00 /SO�O3 PP EFERENCE/./I,
TYPE OF ECTION LENGTH FROM
OWNERS PERMIT $ 1 00 fCuRff3 M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS-------------_----DAY OF............_�------......:..........19...-... NEW HOUSE SEWER {,
OWNER OR CONNECT ADDITIONAL
OWN ERS AGENT----------------•-------------------•--.-.._...------ -------- BUILDING OR WORK
ADDRESS........................................... ....... SEPTIC TANK,SEEP.PIT(8)
- - _ -- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL DRYWELL E]CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/ST LICENSED IF REQUIRED BY LOS THEN �S COUNTY
AND STATE OF CALIFORNIA OR T14AT I AMT E L OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RE! ENTIA PRO E TY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)[-] CESSPOOLS❑
SIGNATURE
OF P E R M I T T E -f-------
76A642D 663 1/53 s"