HomeMy Public PortalAbout5016 GOLDEN WEST AVE_Sewer__ s D>EPAInEMDENr OF OOUNTY ENCUNEMB SEWER.—SEWAGE DISPOSAL 1
" -,DIVISION OF BU LDING AND SAFETY PERMIT APPLICATION
COUNW OF I.Oe AivGET.>01a
` WILLIAM J. FOX. COUNTY EMOIN[ER BUILDIN
ADDLED[
FOR APPLICANT TO FILJ, IN LOOALITY
BUILDING / NEAREST
ADDRESS CROSS ST. a►/
LOOALITY • DIST7NO. Rudy for InspectionpERMIT� J
NO. c
NEAREST ` .7T�IJ /
CROSS 8T.
CIL
RECEIVED BY DATE UE BY DATE
OWNER ! �� /L'. } .
MAIL
DRESS USEZONE OCOUPANOY lm*PPi
AD/
OITY TELMO. , "r O
CONTRACTOR OO.IMP.NG. t7�
ADDRESS (}[D � �j( �/ JOB.NIX
CITY }[/ TELNG; g 1 TRUNK PERMIT NO.
STATE a/
REGISTRATION M0. ROAD PERMIT M0.
LEGAL
DESCRIPTION LOT N0. STATE ENCROACHMENT
Q S PERMIT NO.
BLOCK � WASTE A INDUSA ROVAL
SIZE OF LOT / NO0.WOOFNBLD .
NSCHARGES
LOT
USE
BUILDINGS CONNECTION CH E FEE
�
NO. DE8CRIPTIt3N OF WORK FEE
REIMBURSEMENT FE[
PUBLI0 SEW R ME N 41 + ILN RECEIPT NO. AT[ BY
HOUSE SEWER CONNE-TINA TO
PRIVATE DISPOSAL SYSTEM Im
-ffNN D ITI 0 111 A B Z-6-F-1 EXCEPTION REDOR
WORK TO HOUSE SEWER I.Dl
ALTER OR AEPAIR EXIBTIN NG. DATE
SEWER OR DISPOSAL SYSTEM Im
iff-scoNkttY AND ABANDON SEINER
AND/OR DISPOSAL SYSTEM Im CONNECTION DATA
8 P—TIC TANK,SEEPAGE R
PITS AMD ORAINFIELD 2A6 STATION 11 .Q DEPTH
P —DDRW LL r 157 .5MANHOLE REFLERENCE
SPECIAL CONDITIONS ONLY 2-m
U P P E R 12oYl9(i
TYPE OF CTI 0N LENGTH FRON
Y. P.L. M.L TO P.L.OWNERS HERMIT i I OD
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRAOTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INOR'SSIGNATURE DATE
DWELLING TO THE PUBL10 SEWER
SIGNED THISS-PAY OF 19_ NEW HOUSE SEWER
OWNER OR Aa DCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIO TANK SEEP.PIT(S)
ADDRESS AMD/OR DRA NFIELD
' HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- OE""OL[] DRYWELL
CATIONAND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS, NAd L DI AL 8Y8TEM
I HEREBY CERTIFY THAT IAM PQOPERLY RESISTER[D
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN- ABANDON HOUSE SEWER
EK OF THE ABOVE DJSCRIBED BEAUDENTIA4,FMOPEATY. 6AWFILL GEPTIO TANKA[]
SIGNATURE &nnS[EP.PIT(S)E] 0[SSPOOLi E1
OF PERMITTEE
76ABM SS,➢eQ3 4/64