HomeMy Public PortalAbout5226 GOLDEN WEST AVE_Sewer__ CE808 2/70 APPLICATION FOR PERMIT
76A 642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER / \
BUILDING AND SAFETY DIVISION BUILD'ss v�aCD U.l�
JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W JENKINS. SUP T OF BUILDING 1
LOCALITY e►ti-N i
FOR APPLICANT TO FILL IN NEAREST
(PRINT OR TYPE ONLY) cRoss 57
LEGAL
DESCRIPTION LOT NO OWNER
1�� MAIL
BLOCK TRACT ADDRESS
SIZE OF LOT O` / I NOWOON LOTS O CITY �� TEL NO
USE OF
BUILDINGS '2�ZA.G y, DISTRICT N�GROUP CLASS'l MAP PROCESSED BY
BK pG
r
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO OLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER @ 33 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO
PITS AND/OR DRAINFIELD ® sl0 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 D.
CONNECT ADDITIONAL BLDG OR ..it AFFIDAVIT WAIVER EA51M[NT RECORD INSTR NO DATE OU
WORK TO HOUSE SEWER Q $300 E•��
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE 0 35 00 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING0
SEWER OR DISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT A (�
PERMIT NO W
a
INDUSTRIAL � h
WASTE APPROVAL Z
CHAR ES
OWNERS PERMIT s � 00
AUTHORIZATION TOTAL FEE /1-/1 CONNECTION CHARGE FEE
1HAVE 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 fGNATURE
SIGNED THIS D i" OF at
OWNER OR NEW HOUSE SEWER 7 GL�
OWNERS AGENT 'E" / CONNECT ADDITIONAL �IVi
ADDRESS ��P �/[ 'P �� BUILDING OR WORK r
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OSEPTIC DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING v �� A
PLUMBING AND SEWERS CESSPOOL El DRYWELL /7
I HEREBY CERTIFY THAT I M PR L
CEY REGISTERED AND/OR ALTER REPAIR SEWER OR
LINSED AS REQUIRED S A L COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I E L A OWNER OF AND INTEND TO DISCONNECT PLUG AND 3
RESIDE IN THE ABOV SCR I D SIDENTIAL PROPERTY ABANDON HOUSE SEWER 4
SIGNATURE
OF PER.f TEE BACKFILL SEPTIC TANKS ElSEEP PIT(S) ❑ CESSPOOLS ❑
VALIpATION JACK R. ALLEN
CK' I M 0 CASH SUPERVISING MECHANICAL ENGINEER
LAC0
,
2697: UL7 5 1. v D 6.00-
I
DEPARTAfENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT
/APPLICATION
COUNTY J. O LOS ANGELES I I �2 Gs(v /
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /
ADDRESS �SfJ �[rp MSB_Q
FOR APPLICANT TO I LOCALITY
BUILDING NEAREST
ADDRE CROSS ST. /!// / /fj a yj L•
LOCALITY ���7�/� � DISTRICT NO. Ready for Inspection PERMIT NO.
NEAREST 100, I 3t 12 1 S
ROSS T E ,.IVED- 9 % �yl TE ISSUED BY6, DATE
OWNER �
ADDRESS tiUSEZONE OCCUMAIL PANCY v MAPBK Pe
J
CITY^� TEL.NO,
CONTRACTOR / T 0 S 2— — f�
CO.IMP.N0. 7,.7
ADDRES8�1'-��9 JOB.NO.
ClT E TE L.NO4�loalpj TRUNK PERMIT NO.
ATE
REGISTRATION NO. COUNTY' ROAD PERMIT NO.- ,, Ito 7 9 4
LEGAL
DESCRIPTION LOT N0STATE ENCROACHMENT
.
— , PERMIT N0.
BLOCK TRACT INDUSTRIAL .--�-��
WASTE APPROVAL
SIZE OF LOTeFC�� NOW O.OFON LOT BLDGB. ` CHARGESUSE OF
N
BUILDINGS ��/���j�!g Fie 45 `z�llell�r CONNECTION CT.ION CHARGE FEE
NO. DESCRIPTION OF WORK FEE \
HOUSE SEWER CONNECTING TO REIMBURSEMENT-FEE
PUBLIC SEWER a i 3.59 .1 �6 RECEIPT NO. I\ DATE I BY
HOUSE SEWER CONNECTING TO ' �
_ PRIVATE DISPOSAL SYSTEM 1.00 -
CONNECT ADDITIONAL BLDG.OR _-.-EXCEPTION R CE ORDEO
_ 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 i
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGEPIT OR ' 4? 2 a
PITS AND/OR DRAINFIELD 2A0 STATION DEPTH
— CESSPOOL—DRYWEII ��
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
i UPPER IOyiEii'
TYPE OF CONNECTIONS LENGTH FROM 1
OWNERS PERMIT $ 1 00 Y. CURB (/ P.L: - M.L.TO P.L. /
AUTHORIZATION I TOTAL FEE
IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE D�TE
DWELLING TO THE P BLIC SEWER _
SIGNED THIS_ r ..D p — NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_. _ 1___ � _._ BUILDING OR WORK
_ ...._
SEPTIC TANK,SEEP.PIT(S)
�L _. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL
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 SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE D CRISED ENT L PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(8) CESSPOOLS I
OF PERMITTEE..._.
76A642D S&E 663 4/54