HomeMy Public PortalAbout5203 GOLDEN WEST AVE_Sewer__ DEPARTMENT OF COUNTY ENGWEER i SEWED—SEWAGE DISPOSAL
{ DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES ,���[
WILLIAM J. FOX, COUNTY ENGINEER j BUILDING
ADDRESS ZO�j (� {��pJ
FOR APPLICANT TO FILL IN LOCALITYBUILDING NEAREST //44��
ADDRESS { 0 W ® ' , CROSS ST. LJ — D �a�Y\ y r
LOCALITY DISTRICT NO. SE¢RIIiAL NO. f PE/R IST`N0. c /
NEAREST Ft `J GO Ad J �bJ J
CROSS ST.
ffDBh Ready for Inspection DATE ISSUED
OWNE /q�
MAILC9 Q JT �0 a J ..
USE ZO E OCCUPANCY I MAP
ADDRESS
CITY �� TEL.NO., d
�-c� s 1 BK PG
CONTRACTOR I
(' ' CO.IMP.NO.
ADDRESS ��� JOB.N0. ��
CITY- TEL.NO. �� TRUNK PERMIT NO.
STATE
REGISTRATION N0. COUNT),' ROAD PERMIT N0.
LEGAL % �, STATE ENCROACHMENT c
DESCRIPTION LOT NO. !�
PERMIT NO.
BLOCK TRACT / t'4 Q4� J INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.-OF BLDGS. ! CHARGES
NOW ON LOT 1
USEOF
BUILDINGS ( CONN ON CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT
PUBLICSEWER 3.50 I S RECEIPT NO. BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 1
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING N0. DATE I BY
SEWER-OR DISPOSAL SYSTEM 1.00 t
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 -4'CbNNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION 1� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I rO / MANHOLE REFERENCE
UPPER
TYPE OF CONN CTION LENGTH FROM l
Y. M.L.TO P.L.
OWNERS PERMIT $ I
AUTHORIZATION 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
NEW HOUSE SEWER
SIGNED THIS___.-- --_----DAY OF._..----•----•----__-•-- . -I�-'-
OWNER OR CONNECT ADDITIONAL
-
--• - •--
OWNERS AGENT "�__� _ ter_-_y_g._.@
BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDR .F?.?�'°j'_. ................. AND/OR DRAINFIELD
I 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/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY' ABANDON HOUSE$EWER
ACID STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Ej
SEEP.PIT(S)F] CESSPOOLS[]
SIGNATURE
OF PERMITTEE_ ._ _ ._ _ �_ J
76A642D 663 1/53