HomeMy Public PortalAbout5400 GOLDEN WEST AVE_Sewer__ 4
CEE 8088001REV,6/781 APPLICATION FOR PERMIT
®i
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK PG MAP PROCESSED BY
BUILDING
ADDRESS
CONNECTION DATA
LOCALITY `-•'
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE LOWER
OWNER TYPE OF CONNECTION LENGTH FROM
MAIL Y. CURB P.L. M.L.TO P.L.
ADDRESS
P.C.NO.
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO,I DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR - WASTE APPROVAL
ADDRESS CHARGES
CITU TEL.NO. CONNECTION CHARGE FEE a
STATE LIC. REIMBURSEMENT FEE O
L
LICENSE NO. - CLASS -
NO, DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE W
_e
HOUSE SEWER CONNECTING TO LL.
PUBLIC SEWER NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK.SEEP.PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL DRV WELL❑ ; W
EXTN..CESSPOOL.DRVWELL,MANHOLE H
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS 0
OWNER'S
Permit Si SEEP.PIT(S)❑ CESSPOOLS❑
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT ...
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT IAM THE LEGAL OWNER OF.AND INTENDTO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. -
SIGNATURE -'
OF PERMITTEE
pg,.