HomeMy Public PortalAbout5335 GOLDEN WEST AVE_Sewer__ 7Eaoe28se APPLICATION, I°OR ,PEFiMIT ,-, -
COUNTY OF LOS ANGELES, ,'SEWER=SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER-- '
BUILDBUILDING AND SAFETY DIVISION ADDRESS • .
ADDRESS
JOHN A. LAMBIE, County Engineer ry►
CASSATf D. GRIFFIN, Supt of Building LOCALITY /
NEAREST
FOR APPLICANT TO FRI IN _' ceoss sT.LEGAL
C/ ��/.._.•
DESCRIPTION VTION LOT NO. j/� OWNER i ' 1.
^ "
BLOCK TRACT MAIL y�, %Cc � ADDRESS
.-. -NO.OF BLDGS.
SIZE OF LOT Q�C Z NOW ON LOT; - CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP P40CESSED
BK PG
CONTRACTOR/O,
ADDRESS5-_�G/-// 5f/19' &_792— .4 0.-
CONNECTION DATA
CITY �s TEL.NO, STATION DEPTH
/' UPPE
REGISTRATION N0. ! �' u COUNTY 'MANHOLE,REFERENCE
No _ DESCRIPTIO OF WORK FEEHOUS '
PUBLICR
SSEWECONNECTING TO $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION- LENGTH FROM
PITS AND/OR DRAINFIELD $3.00 Y. CURB P.L. - M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EX TN..CESSPOOL,DRYWELL,MANHOLE @ $2.00 -
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 - CO.IMP. NO. JOB N0.
.CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK'PERMITNO. - 'ROAD PERMIT N0.
SEWER REPAIR
RD 3POSAL SYSTEM HOUSE $1.00 STATE ENCROACHMENT
PERMIT NO. r
INDUSTRIAL
WASTE-APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL•FEE. REIMBURSEMENT FEE
I HAVE AT THIS DATE A.CONTRACT WITH THE HEREIN NAMED CON. ROVALS D TE v INSPEC S GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC-SEWER. r
SIGNED THIS nAY OF _19- New HOUSE SEWER
OWNER ORCONNECT'ADDITIONAL '
OWNERS AGENT BUILDING OR WORK
SEPTIC.TANK,SEEP,PIT(S) - -
ADDRESS AND/OR.DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE,TO COMPLY CESSROOL❑. DRYWELL❑
LESCRIBED
COUNTY ORDINANCES AND STATE LAWS- REGULATING
ALTER, REPAIR;SEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND" _
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF pgANDON',HOUSE SEWER
iIA OR TH I AM E 'LEGAL"OWNER OF THE ABOVE
D I D TI RO TY. BACKFILL SEPTIC TANKS❑ _
SEEP,PITS ❑ CESSPOOLS '
EITTE
L®F VAUDATIO ROBERT A.WOOD
`1CK: U.9. R- SUPERVISING MECHANICP.L ENGINEER
". �.> o� 6 9 0 3 a;- �-1ter,Y.2 2 0 A 5.0.0 � =
M