HomeMy Public PortalAbout5229 GOLDEN WEST AVE_Sewer__ D
S&E-6 _89 1f-33 APPLICATION FOR PERMIT 1
S&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los AngeieaBUILDINGSS
JOHN A LAMBIE, COUNTY ENGINEER ADDRE
® CASSATT D GRIFFIN, SUPT of BUILDING LOCALITY l
NEAREST �= /
FOR APPLICANT TO FILL IN CROSS ST. i ,t
LEGAL / /
DESCRIPTION LOT NO !/
- / OWNER �,
MAIL
BLOCK TRACT r� / AD RESS �.vr�✓(fit
/ NLO'.OF BLDGS
SIZE OF LOT ( NOW ON LOT / CITY �j, TEL NO
USE OF
BUILDINGS .! DISTRICT NO GROUP MAP
�" �C n
5' P7 .
CONTRACTOR Z / `.
CONNECTION DATA Y
ADDRESS ,j
STATIONDEPTH
CITY J TEL. NO. MANHOLE REF ENCE UPPER
STATE LOWER
REGISTRATION N0. �J ❑ COUNTY y
NO DESCRIPTION OF WORK FE
HOUSE SEWER CONNECTING TO TYP OF CONNECTION LENGTH FROM
PUBLIC SEWER @
Y. CURB P L M TO P.L
SEPTIC TANK,SEEPAGE PIT OR
ITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD P C NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $ 2 00 CO IMP NO 10B NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO AD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROA ENT
WORK TO HOUSE SEWER @ $100 PERMIT NO. _
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIA/_
SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 00
AUTHORIZATION TOTAL FEE
V REIMBURSEMENT FEE _
I HAVE AT THIS DATE A'CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S NEW HOUSE SEWER
SIGNED THIS DAY OF� CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGE NT4Z4. ,O T
SEPTIC TANK,SEEP, PIS)
ADDRESS-522f AND/OR DRAINFIELD - -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM U S
I HEREBY CERTIFY THAT I AM PROPERLY REGI ED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY OS ANGELE COUN AND STATE OF DISCONNECT
ABANDON HOUSE SEW D
CALIFORNIA OR THAT 'hf THE LEGAL OWN R OF_ T E AB •E _
ER
DESCRIBED RESIDENTI ROPERTY / / BACKFILL SEPTIC TANKS❑
SIGNATURE ' SEEP. PIT(s) ❑ CESSPOOLS[I
OF PERMITTEES
JOHN A. LAMBIE, Co.Uqey ENGINEERLIDATION ROBERT A WOOD, CHIEF PLBG.rIINSPECTOR
N
CK. �co
0. FSH � VLI 2 8-1 O A 3•W O l'7