HomeMy Public PortalAbout5341 GOLDEN WEST AVE_Sewer__ S fi
ae-663 APPLICATION F'OR, PER,MIT
' DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D ISPOSAL
Deparhaent of County Engineer
•
'County Of LOS Angeles BUILDING
JOHN X LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILP IN NEAREST
g�s p CROSS ST. -•� - ,
LEGAL S. I ' _ V OWNER
DESCRIPTION LOT NO 1
BLOCK TRACT ®� S� MAIL
ADDRESS
NO OF BLDGS. CITY - TEL. NO. -
SIZE OF LOT NOW ON LOT
USE OF DISTRICT GROUP I BK MAP
BUILDINGS
P
CONTRACTOR'
ADDRESS - CONNECTION DATA
t
STATION DEPTH
CITY EL. N0, MANHOLE REFERENCE / ,-UPPER,)
❑ STATE
REGISTRATION NO. - v 7f [ICOUNTY
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P L. M L. TO P.L'.
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD _ nn P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO. IMP N0. 30 JOB NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM - @ $1 00 TRUNK PERMIT NO. ROAD PERMIT N%b 15-4?
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT _
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE - INDUSTRIAL _
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT t '00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- APPROVALS DATE INS ECTOR'S'SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING'DWELLI G
TO THE PUBLIC SEWER. I NEW HOUSE SEWER ?S
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL'
OWNER OR - BUILDING 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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR THAT I AM T LEGAL OWNER fff���F THE ABO
DES IBED RESIDENTIAL PROPE TY �� BACKFILL SEPTIC TANKS❑ ,
SI AT R SEEP PITS) ❑ CESSPOOLS El
JOHN'A L4fBIE. COUNTY ENGINEER VALIDATION' ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N 0 CASCAS J '
• > o6 4 1 me26 4 -4.50
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