HomeMy Public PortalAbout5405 GOLDEN WEST AVE_Sewer__ tD
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REV.6/781 APPLICATION FOR PERMIT
Os
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP BE MAP PG 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 WAIVER EASEMENT RECORD.INSTR.NO. 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
CONNECTION CHARGE FEE
CITY TEL.NO. a
STATE _ LIC. f REIMBURSEMENT FEE 0
LICENSE NO. :.:-r` CLASS -
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE w
J
HOUSE SEWER CONNECTING TO v
PUBLIC SEWER _
NEW HOUSE SEWER
SEPTIC TANK.SEEPAGE PIT OR W,
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CSEPTIC TANK,SEEP,PIT(S) 0ONNECT ADDITIONAL BLDG.OR j
AND/OR DRAINFIELD
WORK TO HOUSE SEWER d
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL E] DRV WELL❑ W
EXTN.,CESSPOOL.DRYWELL.MANHOLE N
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❑
Permit 5 SEEP.PITISI❑ CESSPOOLS
OWNER'S VALIDATION
AUTHORIZATION TOTAL FEE
IHAVE 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 - 1.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MBING AND SEWERS.
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE