HomeMy Public PortalAbout5338 GOLDEN WEST AVE_Sewer__ ' 'Jd` _24650 INSERTS,
`CE8088.80 Y 76A842D APPLICATION FOR PERMIT - , '' '
COUNTY OF LOS ANGELES SEWED-SEWAGE ~DISPOSAL ,
DEPARTMENT OF,COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS' .
, '
JOHN A. LAMBIE, CountY',Eng�neer
WILLIAM A. JENSEN, Supt of Bui)d!l!4`- ;t LOCALITY'
NEAREST 1 -
FOR APPLIC TOr, CROSS ST.
LEGAL" r
DESCRIPTION LOT N0. 'OWNER _ •
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY _ TEL 'N'
0. .l
—BUILDINGS peUL - DISTRICT N0. GROUP MAP PROCESSED BY
- BK
CONTRACTOR
ADDRESS CONNECTION DATA -
CITY EL NO 3a STATION DEPTH
REGISTRATION NO ��— STAT TY 'MANHOLE REFERENCE - - I > UP'tbMfCR•
NO. . DESCRIP-nON OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 'TYPE OF CONNECTION LENGTH FROM
PETS AND/OR PTIC D EEPAGELDT OR @ $3 00 Y. CURB P.L.' M.L.TO P.L.
OVERFLOW SEEPAGE PIT DRAINFIELD '
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP N0. JOB NO. P.
Y,
CONNECT'ADDITIONAL BLDG OR "TRUNK PERMIT NO. ROAD PERMIT NO. O
WORK TO HOUSE SEWER @ $1 00 V
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT Pq
SEWER OR DISPO AL SYSTEM @ $1 00 PERMIT NO
'INDUSTRIAL
WASTE APPROVAL
CHARGES v)
OWNER'S PERMIT, $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 6D REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN,NAMED CON- _ _
TRACTOR TO CONNECT.THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS SATE. INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS D F 19_ NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL - /
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.FIT(S)
_ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE-THAT I HAVE READ THIS APPLICATION -• - - - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
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 REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AN S COUNTY AND STATE OF ABANDON HOUSE SEWER - - - - - - -
CALIFORNIA OR THAT I AM TH LE OWNE5 OF THE ABOVE -
DESCRIBED RESIDENT ROPE R41 Y. BACKFILL SEPTIC TANKS ❑
SEEP PIS) El CESSPOOLS El - --
SIGNATURE T
OF PERMITTE
®r VALIDATION ROBERT A. WOOD
Cs M.0. GSH SUPERVISING MECHANICAL ENGINEER L
03 Dt " 7 0 0