HomeMy Public PortalAbout5323 GOLDEN WEST AVE_Sewer__ 42D 0-63
76A66A842APPLICAT&NFCOR' PE MIT
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 %L CROSS ST
LEGAL M
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF _ r_
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
�f/�
BK PG
CONTRACTOR
ADDRESS V CONNECTION DATA
CITY EL NO
t• S ATION DE• H
S ATEMANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONN TI N LENGTH FROM
HOUSE SEWER CONNECTING TO Y CU L ML TOP L }
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR PC NO O
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO �DV
HOUSE SEWER CONNECTING TO TRUNK PER T NO ROAD PERMIT NO Q[
PRIVATE DISPOSAL SYSTEM @ S3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD CIL
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT E z 00 CHARGES
y CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 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 DA 19_ _
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL � (�
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEPIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFILD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV SCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEEA�rg _KFILL SEPTIC TANKS ❑
EEP PIT(S) ❑ CESSPOOLS ❑
0KVALIDATIONROBERT A. WOOD
M - CASHSUPERVISING MECHANICAL ENGINEER
! io9911- MAR 25 1 0 D 7.00- `v
6 0-63
76A6A642D APPLICATION FOR PERMIT
42 �J
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS y,
WILLIAM A. JENSEN, Supt of Building
L OCALiTY
NEAREST
FOR APPLICANT TO `ROSS ST
LEGAL �
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
1 B=� PG/f
CONTRACTOR / � ��/
ADDRESS r' ano•-Y CONNECTION DATA
O� JJJ
/ATION/ /� DEPTH
CITY TEL N �(
i IJ
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO CESCRIPTION OF WORK FEE TYPE OF CONNECTION NGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L J O}.
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P C NO O
CO IMP NO JOB NO
PITS AND/OR DRAINFIELD @ 51000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00 / (BOO 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ 53 00
OVERFLOW SEEPAGE PIT DRAINFIELD lJJ
EXTN CESSPOOL,DRYWELL M LE @ 3500
ALTER,REPAIR OR ABANDON E HWY OR ST WIDENING h
SEWER OR,111,SPOSAL S,6TE @ $3 00 STATE ENCROACHMENT
PERMIT NO
r
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 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 DA O 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
r CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(5)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO ESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE Y ❑
SEEP PIT(5) El CESSPOOLS
/--)VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
Lt�l�o 9 9 1 2 MIM 2 5 1 1 D 2 5.Q 0-