HomeMy Public PortalAbout5411 GOLDEN WEST AVE_Sewer__ E 808(REV. APPLICATION FOR PERMIT
o5 SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP BK PG MAP PROCESSED BY
BUILDING
ADDRESS ���
LOCALITY /
CONNECTION DATA
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. 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
CITY TEL.NO. CONNECTION CHARGE FEE ASS qq�
STATE LIC. REIMBURSEMENT FEE u
LICENSE NO. CLf
NO. DESCRIPTION OF WORK FEE W
APPROVALS DATE INSPECTOR'S SIGNATU E
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT
AL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S) O
CONNECT ADDITIONAL BLDG.OR
AND/OR DRAINFIELD
WORK TO HOUSE SEWER 4
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL F] DRYWELL El
EXTN.,CESSPOOL,DRYWELL,MANHOLE �,..
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❑
OWNER'S
Permit $ SEEP.PIT(S)❑ CESSPOOLS'❑
AUTHORIZATION I TOTAL FEE VALIDATION
I HAVE 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
ADDRESS •_
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY �= z
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING 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