HomeMy Public PortalAbout5212 GOLDEN WEST AVE_Sewer__ 0-63
76A642D APPLICATIO FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ��
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY 1
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO �� OWNER
MAIL /
BLOCK TRACT ADDRESS / t
N BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP ROC 5 D BY
BUILDINGS BK PG
CONTRACTOR / �� [�.�
ADDRESS I. CONNECTION DATA
CITY ` S T O4 'STATM / / DEPTH
t i L/
STATE MANHOLE REFERENCE
REGISTRATION NO UNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEND FR
HOUSE SEWER CONNECTING TO Y CURB P L M L P
PUBLIC SEWER ES 00I CL
SEPTIC TANK,SEEPAGE PIT OR J C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO 3Q J JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM @ S3 00 w
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIV[R lASf MENT RECORD INSTR N DATE V
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD fJJ
EXTN CESSPOOL,DRYWELL MANHOLE @ E5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR BT WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
_ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR SSIGNATURE/
SIGNED THIS DAY OF 19_ ✓
OWNER OR NEW HOUSE SEWER
OWNERS AGENT ' (
CONNECT ADDITIONAL G L
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY ANSTATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T T I AM THE LEGAL OWNER OF, AN INTEND TO DISCONNECT PLUG AND
RESIDE IN T OVE DESCRIBEENTI PRO ERTY ABANDON HOUSE SEWER
SIGN TUR BACKFILL SEPTIC TANKS ❑
OF PER ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
' CK M O CASH
L Co 2' 6 9 0 G) AUG 17 1 0 D 7.0 0
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