HomeMy Public PortalAbout5142 GOLDEN WEST AVE_Sewer__ DEPAICV31ENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION )
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING _
-'3 ADDRESS
'
FOR APPLICA TO FILL IN LOCALITY
BUILDING q ., NEAREST
ADDRESSK/ CROSS ST. I LO /V
LOCALITY DISTRICT NO. SERIAL NO. PERMIT
NO.
NEAREST A 16�� ®�
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER x/,
MAIL
ADDRESS USE ZONE OCCUPANCY MAP
" ' '
BK PG
CITY _ _ TEL.NO. ?E-5
CONTRACTOR
CO.IMP.NO. !3ea-�-5 '` Z yC.J
ADDRESS
CIT TEL.NO. TRUNK-PER-MIT-NO.
STATE --� 5'
REGISTR ION N0. `� H COUNTY ROAD PERMIT NO.
LEGALDESCRIPTION LOT NO .h /�/ �� STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
^ NO.OF BLDGS.
SIZE OF LOT ' NOW ON LOT __ 9 CHARGES _
USE DI /
BUILDING8 CONNECTIO CN CN HARGE.F.�E
NO. DESCRIPTION OF WORK FEE
HOUS4E SEWER CONNECTING TO RElMBURS NO. FEE j
PUBLIC SEWER Q j 3.50 RECEI IT N0. /DATE` I I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 d
CONNECT ADDITIONAL BLDG.OR I EXCEPTION RECORDED ,
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE 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 i C) + I0'J DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
(/7r up-PE-R• LO EWR
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y� CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE (/
1 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_.... .._, ._..�*'......_.... NEW HOUSE SEWER
� k 30�-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_. __.___.__/'� � _ BUILDING OR WORK
.......................................... .—
ADDRESS---------------_------_...---.._' SEPTIC TANK,SEEP.PIT(S)
-.............._......_.._..__...._-- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
CA
TIONAND 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/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THP I AM THE LEGAL OWN-
ER OF THE AWBGSIRIBED R IENTIAL P OPERTY. BACKFILL SEPTIC TANKS ElSEEP.PIT(S)(] CESSPOOLSSIGNATOFPERMITT = .. - . ......--
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