HomeMy Public PortalAbout5347 GOLDEN WEST AVE_Sewer__ DEPA1trAIENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELS$
WILLIAM J. FOX, COUNTY ENGINEER BUILDING 673
ADDRESS
FOR APPLICANT TO FILL IN /� LOCALITY i
BUILDINGNEAREST
ADDRESS � 4�/y (7tp�LDE�� VIJ��T r-Y CROSS ST.
LOCALITY 7 F M P L E CITY DISTR]�CT NO. SERIAL NO. PERMIT NO.NEAREST j
CROSS ST. � l� ►� �, v A 4 41/ v S
��dRF,F � Ready for Inspeotton L DATE
!.�
OWNER ZC?I.,.£, ;;�L �IfrAMt�1?� !//�C�' (i'�
ADDRESS 43MAIC1� v'"10 WQhIDO All. USE ZON OCCUPANCY
CITY TF A'lPL•F G I TY L.
TENO :T- E;-11'7 I BK PG
CONTRACTOR ;
CO.IMP.NO.
ADDRESS 4 ��
1 ' JOB NO.
l
CITY TRUNK PERMIT NO. .
STATE ^� jj
REGISTRATION N0. - OUNT ROAD PERMIT NO. c y �a
LEGAL �f
DESCRIPTION LOT N0. PCS�1�+! d� �S STATE ENCROACHMENT
67 PERMIT N0.
BLOCK TRACT f, 01.1 ViG,VJ ACPI INDUSTRIAL
SIZE OF LOT -PPROVAL
S j( N0.BF BLDGS. I MVVSE
NOW ON LOT CHARGES
USE OF
BUILDINGS S��EAITI/4� ��AA, C&Wt SCONNECTION CHARGI&FEE O
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ^ REIMBURSEMENT FEE
PUBLIC SEWER ; 3.50 U RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO 1
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR XCEPTI N RECORDED
WORK TO HOUSE SEWER 1.00
ALTER-0—Ft REPAIR EXISTING 0• DATE I BY
SEWER OR DISPOSAL SYSTEM 'I.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 r�` MA H p REFERENCE-, �w E�
TYPE OF CONNECTION�j LENGTH FROM
OWNERS PERMIT ; 1 00 Y. M.L.TO P.L. 3
AUTHORIZATION TOTAL FEE 0/./ oG,�a.� ,� 7Y
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DE CRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO ME ,SEWER) _`
SIGNED THIS '(64AY••QF..u!�-..__�_Y�-' r ._14- `=` NEW HOUSE SEWER 5��,rOC �-
OWNER OR a 7 " �y,/ CONNECT ADDITIONAL
OWNERS AGEN _ _�__^'�_ ._ _._ BUILDING OR WORK
---....r__ - .r__...._.._
A ��' SEPTIC TANK,SEEP.PIT(S)
ADDRES3_ LE._ _ iG�?L- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESC IBED RESIDENT OPERTY.- BACKFILL SEPTIC TANKS
r / SEEP.PIT(S)E] CESSPOOLS[ e
OFSIGPf URE
OF P)=RMITTEE� _._. _.
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