HomeMy Public PortalAbout5325 1/2 GOLDEN WEST AVE_Sewer__ �3 � �,a ��� `J
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5 E-689 11.55 APPLICATION FOR PERMIT 1
S&E•8 -
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE- DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEERADDRESS 5125-2_27 .olden. WAAt
® CASSATT D GRIFFIN, SUP T OF BUILDING Mj LOCALITY Telllnla City
FOR APPLICANT TO FILL IN CROSS ST. '
LEGAL7D Or a OWNER �;}
DESCRIPTION L �0 WE. Owen
MAIL
BLOCK TRACT - ADDRESS '
NO OF BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF - DISTRICT NO GROUP MAP
BUILDINGS - - ,y, - BK PG
CONTRACTOR Earl Pat St dInc J F, V2-
ADDRESS
ZADDRESS 2019 .® HOvt P••O•il-OS, CONNECTION DATA
CITY El Monte TEL. NO.
STATION - DEPTH
-
G MANHOLE REFERENCE - - UPPER
STATELOWER
REGISTRATION NO. 1IF9236 • �❑ COUNTY '
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
Y. CURB P L M L TO P L.
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD P NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO JO NO
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 200 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ t 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 300
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER �� NEW HOUSE SEWER r
SIGNED THIS AY OF 19 CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION• CESSPOOL❑ DRYWELL❑
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 IAM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
'LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE -
ER
DESCRIBED RESIDEN PR Y BACKFILL SEPTIC TANKS C3SIGNATURE SEEP PIT(S) ❑ CESSPOOLS[IOF PERMITTE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG. INSPECTOR
CK M 0. CASH
t il�0 5 4 0. 629, , OCT 1 ,10 ' A 3.0 O N