HomeMy Public PortalAbout5217 GOLDEN WEST AVE_Sewer__ DEPAENT OF COUNTY ENGINEER ' SEWER-SE -WAGE DISPOSAL
167'N 1
DIVISI,0N OF BUILDING AND SAFETY
!PERMIT-APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING` �-7 elt
ADDRESS /V ( �/
BUILDING FFt5[R APPLICANT TO FILL IN LOCALITY
ADDRESS ✓ 2i n 0 / EAS ST /(;J �,
CROSS ST. (�'
LOCALITY LY 1 DISTRICT NO. SERIL � PERMIT N0.
NEAREST , S
CROSS ST. /cam
CE�Bbl Ready for Inspection DATEnISSU�E•D
OWNER-
RE.? 1�40- JX
MAIL , USE ZON(//E OCCUPANCY BK MAP PG��,
ADDRES W
CITY TEL.NO.
CONTRACTO �-.-"4- CO.IMP.NO.
ADDRESS JOB N0. V
G
CITY TEL.NO. TRUNK PERMIT NO. —�
STATE
REGISTRATION NO. B COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 0. F BLDGS. CHARGES
NOW ON LOT
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER 0 $ 3.50 RECEIPT NO. - TE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR ! Gv EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEP IC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION E;W 001
CESSPOOL—D RYW ELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER_
_ TYPE 0 NNECTIONLENGTH FROM
OWNERS PERMIT $ I 00 Y. P L. 141=M•L P.L.
AUTHORIZATION I TOTALFEES _
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I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO TH -P BLIC SEWER
SIGNED THIS_ -- ----DAY OF.., NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL //_
OWNERS AGENT....... .-.. _ BUILDING OR WORK cTG A C✓ T�
_.....--
ADORESS __ Q- _ SEPTIC TANK,SEEP.PIT(S)
-- -• - � �••--•_•--,F_-•• AND/OR DRAINFIELD
1 HEREBY KN
LEDGE THAT I HA READ THIS APPLI. CESSPOOL Ej DRYWELL C]
CATION ANDS 4T THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WIt ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
ANO/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOV CRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP.PIT(S)E] CESSPOOLS�
OF PERMITTEE.. ....... ----
76A642A 663 7/