HomeMy Public PortalAbout5317 GOLDEN WEST AVE_Sewer__ 10-63
76A642D APPLICATIO FOR PERMIT' '
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS (E♦
/ 77=
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST ,s
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO -5 ^,�71_^-LOWNER
ti MAIL
BLOC TACT f ��4]y ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP / MAP P CESSED BY
CONTRACTOR
ADDRESS !lIJJJ CONNEyCTION DATA
CITY TEL NO1,9 STATION C DEPTH
//�� STATE t/ r UPPER
13 REGISTRATION NO rjJ COUNTY MANHOLE REFERENCE ♦ \� A L_®,�
NO DESCRIPTION OF WORK FEE ^- ypE OF CONNECTION LENGTH FROM 1
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L d
PUBLIC SEWER @ $5 00 �'�
SEPTIC TANK,SEEPAGE PIT OR P C NO O
CO IMP NO •J7�!' JOB NO
PITS ANDOR DRAINFIELD $10 00 `' //yj} //(( V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / U
PRIVATE DISPOSAL SYSTEM @ $300 / Ow
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE V
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD Y.!
EXTN CESSPOOL,DRYWELL MANHOLE @ s560
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE 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 SIGNAJURE
SIGNED THIS DAY OF 19 �I �'.�.•y�� P'
OWNER OR �� NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL 4 r
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKN LEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT E ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING r
PLUMBING AND SEWERS ' CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR J
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWA GE DISPOSAL SYSTEM
CALIFORNIA OR THAT I M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESCRIBE RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE "� �� SEEP.PIT(S) ❑ CESSPOOLS ❑ '
OVALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
ACC 9 9 0 8lmo MARR 2 5 1 0 D 7.0 0