HomeMy Public PortalAbout5313 GOLDEN WEST AVE_Sewer__ - D
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APPLICATION FOR PERMIT' ' 1 .
8"&E eDIVISION OF BUILDING AND SAFETY. SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los AngeleB BUILDING3,� 3 o la( 71�e� L
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS �✓
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY T �� (::4
EAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 7 S' OWNER
DESCRIPTION LOT NO.% MAIL
BLOCK TRACT �' �LD� /.Lps ADDRESS
N0. OF BLDGS.
SIZE OF LOT �� , a/'J" NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT NO, GROUP
BK A MAP
PG
CONTRACTOR
ADDRESS CON/NECTION DATA
• STATION ®(F/P {� DEPTH
CITY 5 G� TEL. NO. MANHOLE REFERENCE / UPPER _
Pl--MTE
REGISTRATION NO. Z ❑ COUNTY
NO. . DESCRIPTION OF WORK' FEE
HOUSE SEWER CONNECTING TO E OF CONNECTION LENGTH FROM
Y. M L.TO P.L.
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD 1 P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO IMP NO: vJOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ,Q $1 00 TRUNK PERMIT NO. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT ,
_WORK TO HOUSE SEWER Q $1 00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL '
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE.FEE _ -
OWNER'S PERMIT $ 1 00
REIMBURSEMENTFEE '
AUTHORIZATION . TOTAL FEE C?
•I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- -APPROVALS DATE INSPECTOR SSIGNP.TURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLIN
TO THE PUBLIC SEWERNEW HOUSE SEWER
SIGNED THIS D Y OF b 19� CONNECT ADDITIONAL
'OWNER OR / BUILDING OR WORK
OWNERS AGENT
SEPTIC TANK,SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD .•
I HEREBY ACKNOWLEDGE THAT 1 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 I SEWAGE DISPOSAL SYSTEM -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
,CALIFO A OR THAT I AM THE LEGAL OWNER THE ABOVE _
DESCR RE519ZE TIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIG NfiaMSEEP PITS) ❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIff, COUNTY ENGINEER ALIDATIOROBERT A WOOD, CHIEF PLBG INSPECTOR
CK d 0
110 6- 8 2 7' APR 4 4 4.5 0 �' .
D
S&E-683 if-SS APPLICATION FOR PERMIT - 1
3 8:E•8 -
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depm'tnent'of-County Engineer 7
County ofLos Angeles- BUILDING /G„/��
JOHN A LAMBIE,-COUNTY ENGINEER ADDRESS lJ 3� /V lel /�f J
® CASSATT D GRIFFIN, SUP T of BUILDING LOCALITY 7
FOR APPLICANT TO FILL IN CROSS ST. 9(/
LEGAL OWNER
DESCRIPTION LOT NO.
5
BLOCK - TRACT MAILADDRESS
NO. OF BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO GROUP BK MAP PG
CONTRACTOR ��' � - I —7
ADDRESS �.:.: � CONNECTION DATA
CITY -TEL N0,A1_ STATION DEPTH/
1 MANHOLE REFERENCE UPPER
❑ STATE - LOWER -
REGISTRATION N0. 5F27 9 ❑ COUNTY y ,
NO DESCRIPTION OF WORK FEE ' �1
HOUSE SEWER CONNECTING TO TYPE OF CONNEC ON -LENGTH FROM
PUBLIC SEWER @ $3 50 Y• CURB P L M L TO P.L
SEPTIC TANK,SEEPAGE PIT OR '
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD P C NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO. ' AD PERMIT NO '
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMEN
WORK TO HOUSE.SEWER ' Q $1 00 �.� PERMIT NO. -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM Q $1 0o WASTE APPROVAL ^•
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE - - •
AUTHORIZATION TOTAL FEE ]DN
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM - APPROVALS DATE INSPE CTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING D
TO THE PUBLIC SEWER, - NEW HOUSE SEWER
SIGNED THIS DAY sOF CONNECT ADDITIONAL
OWNER OR � BUILDING OR WORK G ,
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1,HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLCESSPOOL❑ DRYWELLE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO WITH ALL COUNTY ORDINANCES AND STATE LAWS REGALTER,REPAIR,SEWER ORPLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY- CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG ANDLICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STABANDON CTPLUGHOUSE ANDCAWER
LIFORN OR THAT I AM THE LEGAL ,OWNER OF THEE DES CRIB -RES1tDENT1AL PROPERTY. ,iBACKFILL SEPTIC TANKS❑
SEEP. PITS) ❑ CESSPOOLS❑
JOHN A. LAMBI COUNTYENGINEER VALIDATI ROBERT A WOOD,CHIEF PLBG. INSPECTOR
CK. M O. CASH - - -
A 2 8,2 ,8;a_1 .00T 4 2-:0