HomeMy Public PortalAbout5325 GOLDEN WEST AVE_Sewer__ APPLICATION , FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE ®ISPOSAL
Department of County Engineer
County of Los Angeles BUILDING <
WM.J. FOX, COUNTY ENGINEER ADDRESS
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® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS S
LEGAL
DESCRIPTION LOT NO. • OWNER t7,tl
BLOCK TRACTIC�sIO/Y ]� MAIL �i )
a'�i. ADDRESS
SIZE OF LOT S Q S NO OF BL GS. ��
NOW ON LOT CIT TEL. NO.
USE OF
BUILDINGS r DISTRICT N0. GROUP MAP
//� ♦MBK PG
CONTRACTOR �,� ,f
ADDRESS CONNECTION DATA
CITY ocr
�.4T-� STATION DEPTH
IV 4� ❑ STATE MANHOLE R(FEANCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO I//� Y CURB P L M L TO P L.
PUBLIC SEWER Q $ 3 50 J G/
21
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG. OR PC_
NO.
WORK TO HOUSE SEWER 1.00 CO. IMP NO. JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0,
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S S 1 00
AUTHORIZATION I TOTAL FEE I, REIMBURSEMENT FEE
I HAVE TTOS DATE CONNECT THECTED ABOVEWITH THE DESCR DESCRIBED EXISTINGdED DWELLINGCON-
TRACTOR APPROVALS DATE INSP TOR'S SIG TURE `
TO THE PUBLIC SEWER - •- t
NEW HOUSE SEWER '
SIGNED THIS DAY OF 19- I-A730,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
IO ACKNOWLEDGE-THAT t HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
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. -
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERCD AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROF7�7 TY. BACKFILL SEPTIC TANKS
SEEP. PITS) ❑ CESSPOOLS❑
SIGNATURE 7 t-
OF PERMITTEE - -
WILLIAM J.FOX. COUNTY ENGINEER V VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
4.50A04 9 6 9S DEC 10 �. M