HomeMy Public PortalAbout5234 GOLDEN WEST AVE_Sewer__ 76A 642D-CE808-,10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
ADDRESS S:G) 3 G t..DE — R(/�
LOCALITY -E,,rpe-
NEAREST
FOR APPLICANT TO FILL IN CROSS ST sl�F
LEGAL A
DESCRIPTION LOT NO OWNER A yr Klee /&-.-
MAIL
BLOCK TRACT �(„i ADDRESS
14 9 NO OF BLDGS
SIZE OF LOT Q NOW ON LOT ^ CITY TEL NO G�
USE OF
BUILDINGS G G G�� DISTRICT NO GROUP MAP CESSED BY
46 BK PG
CONTRACTOR D �,
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL NO
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO CLASS � LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER @ $7 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD fl0 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO d
PRIVATE DISPOSAL SYSTEM @ $300 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVEII -EASENINT RECORD INSTR NO DATE O 0
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $500 HWY OR 3T WIDENING O
AbTiR REPAIR SE �j� V
SEWER M @ $300 STATE ENCROACHMENT W
MANHOLE $7 00 PERMIT NO d
INDUSTRIAL N
WASTE APPROVAL Z
OWNER'S PERMIT s
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE 4
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTE REPA SEWER OR �
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWA POSAL SYSTEM 4
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED REST TIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP PIT(S) El CESSPOOLS
VALIDATION CK M.O. CASH
58 pa 9.C) C)
DEPARTMENT OF COUNTY ENGINEER i SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER i BUILDING f /
it ADDRES$j_23 A" �I,C O[dcyi We
FOR APPLICANT TO FILL IN LOCALITY rLrn�/B Gi l'y
BUILDING ] NEAREST
ADDRESS ✓P CROSS ST.//6
LOCALITY '`� , DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST
. S
CROSS ST. If/ ✓ 1! RECEIVED BY Ready for Inspection D�7ATp ISSUED
OWNER ae em p 0 4jj eGC
MAILUSE ZONE OCCUPANCY MAP
ADDRESS rP I BK PG
CITY t TELAO. A 35-1
�eis
CONTRACTOR �;c CO.IMP.NO. '13 Qc
ADDRESS Xa 3.Ne JOB.NO.
CITY t� TEL.NO. STATE r` TRUNK PERMIT N0.
REGISTRATION NO. 8 COUNTY ROAD PERMIT NO. 3 ��
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT f C� INDUSTRIAL
WASTE APROVAL
SIZE OF-LOT t7 ly qNO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS h'a g e CONNEC CHARGE FEE
NO. DES RIPTION VF WORK FEE REIMBURSEMENT FEE--_.
SEWER CONNECTING TO
PUBLIC SEWER @ ; 3.50 RECEIPT N0. �� `ATE I BY
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OREXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 '00 N0. I DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION /1 C57 DEPTH 6
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFETCE
- �`' lYlo LOWER
TYPE OF CONNECTI N LENGTH FROM
OWNERS PERMIT $ I 00 CURB P.12. - M L.TO P.L. Z 2
AUTHORIZATION TOTAL FEE I 1-1—ls-0
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWERNEW HOUSE SEW ERT l�ilt � O 2V.3
SIGNED THIS--------------------DAY OF----------_._._---------------- 19...---- _
OWNER OR
CONNECT ADDITIONAL ) (��per}/
2��
OWNERS AGENT------------......---------------------------•------•----...-----• BUILDING OR WORK ,
SEPTIC TANK,SEEP.PIT(S)
ADDRESS ...-----------------..................................... .- AND/OR DRAINFIELD
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL I]
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 DESCRIBED R I ENTIA PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)� CESSPOOLS❑
SIGNATURE
OF PERMITTEE - - o.. -. ... - ------
76A642D 663 1/53