HomeMy Public PortalAbout5321 GOLDEN WEST AVE_Sewer__ 6 0-63
76A6A642D APPLICATION/FOR PERMI
42
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOAN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building �7a {--
LOCALITY C..fjG
NEAREST t
FOR APPLIC T TO 'LINCROSB BT
LEGAL n
D71
ESCRIPTION LOT NO .!� OWNER
If
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP CESSED BY
BUILDINGS BK
CONTRACTOR � '� �Pl� �
ADDRESS , � CONNECTION DATA
CITY - TEL NO Y{ ATION DTH
ST-ATE MANHOLE REFERENCE NP3sit—
REGISTRATION NO COUNTY 2 LOWER
NODESCRIPTION OF WORK FEE TYPE OF CONNEC l LENGTH FROM
HOUSE SEWER CONNECTING TO �� Y CU P L M L TO P L
PUBLIC SEWER @ $B 00 }
NO O_SEPTIC TANK,SEEPAGE PIT OR CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD @ 51000 PC
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM � $300 9x
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER IIASK.ENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 U
OVERFLOW SEEPAGE PIT,DRAINFIELD {1A
EXTN,CESSPOOL,DRYWELL MANHOLE @ $500
HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL '
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION FTOTAL 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 SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER C
OWNERS AGENTCONNECT ADDITIONAL { " rV
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AT PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE N
DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE
SEEP,PIT(S) [:] CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
LrtLo 9 9'0 9�2 FiM 2 5 1 0 D 7.0" 0- L"
0
766A -63 APPLICATION FOR PERMIT
A642 642D"
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO DRG55 5T
LEGAL r /
DESCRIPTION LOT NO / OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE ILDI1 DISTRICT NO GROUP MAP PRO ESSED BY
BUNGS
B K PG
CONTRACTOR
ADDRESS - CONNECTION DATA
CITY EL NO � ATION DEPTH
r n
STATE MANHOLE REFERENCE
REGISTRATION NO LJ COUNTY . LOWER
NO DESCRIPTION F W RK FEE TYPE OF OUfjkdTION` LENGTH FROM 5 3c)
HOUSE SEWER CONNECTING TO Y P L M L TO P L �J
PUBLIC SEWER @ S5 00 �� }
SEPTIC TANK,SEEPAGE PIT OR P C NO d
PITS AND OR DRAINFIELD S1000
CO IMP NO -108 NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $3 00 �10 6 V
Q[
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER eASrMrxT RECORD INSTR NO DATE Or
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN CESSPOOL,ORYWE 4,MA NH OLE @ E5 00 O.
ALTER REPAIR OR ABAN O HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL S ,5 @ S3 00 STATE ENCROACHMENT Z
PERMIT NO
- INDUSTRIAL
WASTE APPROVAL
OWNERCHARGE
S PERMIT S -
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE / .
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA MED C;N-
RACTOR TO ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY SF 19_
OWNER OR j NEW HOUSE SEWER
OWNERS AGENT ! CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB .E ESCRIBSIDENTIAL PROPERTY RTS ABANDON HOUSE SEWER
SIGNATURE `7•/ BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT 15) E3 CESSPOOLS ❑
/1 VALIDATION ROBERT A. WOOD
CK M o CASH SUPERVISING MECHANICAL ENGINEER
LiA609 9 1 0'no MAR 25 1 1 D 25.00-