HomeMy Public PortalAbout4947 GOLDEN WEST AVE_Sewer__ 7eAd2e
CE°08" ° °' APPLICATION FOR PERM-IT
mI " _
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGEM BUILDING AND SAFETY
FOR APPLICANT TO FILL IN °� K° 4WUP I SK M" pq P"OC13S
pua.DrnG �/-�8 "63
ADDRW
LocwLrrr
-CONNECTION DATA
NIA11El'f STAn ON DEPTH '
crow ST.
urPER
YANHOLB RL Pf RENCI LOWER
OWNER TYPE OR cotmmc-nok FROM .
MAIL �� Y. CURB PLL M1 TO PJ_
ADO RENS
.I 1 Pr_NO. r
I' CO.IMP.NO. JOB NO.
C Td NO.
LffbAL TRUNK PERMIT NO. ROAD PERMIT NO.
DRBC.RnPML LOT D. .
APPIDAVff WAVER EA•Jim EmT G
REORD.INR.
STNO. DATE
BLACK TRACT -
v NO.OF■LDGS.
SIVE OP LAT F� O NOW ON LOT HSYY.OR ST,WIDENING
-BE
OP
hu ..DING. Q STAT[■NCROAr_HMKNT
PERM IT NO.
U41DUSTRIAL
CONTRACTOR j WASTE APPROVAL
A:Dr.)km B CHARGES
COHNBCTION CAGE FS■
CIT' T1HR
L NO.
STATE LEC, RE W B u RS E M f NT FE E
LJCENS[NO. CLAAS
NO. DESCRIPTION OF WORK PAN APPROVALS, DATE C"OR's MFGHATURE
HO(JSEBEWER CONNECTING TO
PUBLIC DENIER
BPTIC TANK uEPAOE PITOR' NEW HOUf[f[IMER ..
PITS AND/OR DRAltf1EL1) CON NZ Ct ADDfTK?NAL
HOUSE SEYYER CO iNECTNNG TO ■ULDLNG OR WORK /r
PR NATE DIBPOBAL SYSTEM fE glC_TAN K.BE KP.Prr(B)
GONN ECT ADDmoftAL■ .OR AND/0R Ow NPIE1D
.WORK TO HOUff1 R. v
OVERFLOW BEETAGf PIT,DRAINPIELD CESSPOOL ❑ DIfYWELL❑
wcrN_casspoot,DRywKu_MANHOLE
ALTS R.REP/OR Of!ASANDON HOUR■ ALTER,REPAIR,SEWER OR
B EWER OR.D IBTOBAL■YSTE M S[WAG f DISPOSAL SYSTEM
--.- PNICONNECT PL UCCA ANQ
ABANDON HOUBn BEWER
Permit
f
BACKFILL S KPT+C TANKS
OWNER'S ❑ _.
Fermit S SEEP.Prrta)❑ L`E.f1POOLf El
AUTHORIZATION
L.1
AUTHORIZATION TOTAL FEE QU VALIDATION
I HAVB AT THIB_DAT[ A GONT'I1ACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DSSCRIB[D WUSTING DWJLLING ;96828A
TO TH l PU 4LIC SfvnM
SIONSDTHIS ' DAY OF 19_ '# o 0,0 0-1 O
OWNER OR q .
OWNERS AGENT L O 01400
._
ADDRHBS
1 HEREBY ACKNOMYLf DGE THAT I HAVE READ THIS APPLJGATION - .O,O_ O 1 -4 O 0
ND
ASTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 09,24-79
I �J
WITH ALLµq NNETYWf�INANCEf AND STATE LAWS REGULATING _ U 9,2 4- '/ 9 -
I H[RBBY CkERTTY THAT I PROPERLY REGISTERED AND/OR
LJC41KBED AS RMD MY 4.MKI-Y AND RTATR OF
CALJ PORN RE OI AM THEA q%"KR O AND QlfENDTO Rd- .
SIDE IN,THE ABOVE CS f.¢GR IB ILD-RAS OWMAL PROPS -
01 NATU RE- ..OF PERMITTI¢