HomeMy Public PortalAbout5406 GOLDEN WEST AVE_Sewer__ 76A6
CE 808 08(REV.6/78)
tI APPLICATION FOR PERMIT ��//yy((►►
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING --
BK PG
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY
ADDRESS -
CONNECTION DATA
LOCALITY
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLEREFERENCE
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 EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT -
NO.OFBLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR WASTEAPPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE a
STATE LIC. REIMBURSEMENT FEE O
LICENSE NO. - •/ CLASS
NO. DESCRIPTION OF WORK FEE W
APPROVALS DATE INSPECTOR'S SIGNATURE �_
HOUSE SEWER CONNECTING TO A {L
PUBLIC SEWER �� �
SEPTICTANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP.PIT S) O
PIT(
S)ADDITIONAL BLDG.OR
AND/OR DRAINFIELD
d
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL❑ W
EXTN.,CESSPOOL,DRYWELL.M ANHOLE H
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER ORD ISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
SEEP.PIT(S)❑ CESSPOOLS
OWNER'S Permit s
AUTHORIZATION TOTAL FEE VALIDATION
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ -
OWNER OR
OWNERS AGENT W R' ; 1,
ADDRESS
IHEREBY 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 t .
PLUMBING AND SEWERS.
I HEREBY 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