HomeMy Public PortalAbout5319 GOLDEN WEST AVE_Sewer__ G r.�tG
DEPAWrMENT OF COUNTY ENGINEER
SEWER®SEWAGE ®ISP6SA1.
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES '
WILLIAM J.-FOX, COUNTY, ENGADDRESS
INEER I
BUILDING��i��2� D /n-�f f�
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FOR APPLICANT FILL IN
LOCALITY
BUILDINGNEAREST
ADDRESS CROSS ST. �we
LOCALITY J + DISTRICT NO. p ' SERIAL NO. PERMIT`_�
A
C
NEAREST
CROSS ST. J' RECEIVED BYReady for Inspection,- D TE IS
ED
OWNER 1,51el q
MAIL USE OCCUPANCY B AP PG
ADDRESS
CITY TEL.NO.
CONTRACTOR ` - i CO.IMP.N0,
ADDRESS '/ nt.." JOB NO.
CITY TELAO. TRUNK PERMIT NO.
REGISTRATION NO. - C;0000UNTY,? ROAD PERMIT NO.
LEGAL 2 72— e::2
�� 7 a
DESCRIPTION LOT'NO. 7� SZ 2 S.O STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT �S�O ���(/�JL� r INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 7S_ 3 35NOW ON LOTS �/� ; CHARGES
USE OF
^� �
BUILDINGS c- /�� CONNECTION CHARGE FE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 .*7 : RECEIPT NO. ATE I BY
' HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR 1 .,'EXCEPTION REC RDED
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
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA �•,
SEPTIC TANK,SEEPAGE PIT OR ,�
PITS AND/OR DRAINFIELD 2.00 STATION Ag DEPTH
CESSPOOL-DRYWELL + ,<
SPECIAL CONDITIONS ONLY 2.001 MANHOLE REFERENCE
p ,mgr=RRy LOWER
TYPE OF CONNECTIONr LENGTH FROM
OWNERS PERMIT $ 2i 00 Y. �G_U,RB %dWl! M.L.TO P.L.
,AUTHORIZATION TOTAL FEE /� . �{ /"y
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMEDI
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_.....5 .._DAY OF.__ J�f_.�._._.__.._.,19d%; NEW HOUSE SEWER Q�k S`7 g
"OWNER OR ^ CONNECT ADDITIONAL
OWNERS AGENT.-� ` �1.._._-_-�__-._._...._._._.._1 BUILDING OR WORK -
" SEPTIC TANK,SEEP.PIT(S)
ADDRESS.------------------ ._._..............-....-.---.-_•----..--•• AND/OR DRAINFIELD
I,HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 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 CALIFORNI R THAT I AM THE LEGAL OWN-
ER OF THE ABOVE,42SC D>RESIDEN IAL PROPERTY. BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP.PIT(S)E] CESSPOOLS El
OF PERMITTEE ._.. - -- _... - •-_---- --_--------._.._.-
76A642A 663 7/53 IV