HomeMy Public PortalAbout5414 GOLDEN WEST AVE_Sewer__ 76Ab42D
`EB°R'REV 6 'R APPLICATION FOR PERMIT
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
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.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 qd
STATE LIG. % REIMBURSEMENT FEE V
LICENSE NO. CLASS '
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
T HOUSE SEWER CONNECTING TO v
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT
AL
HOUSE SEWER CONNECTING TO BUILDING OR WORK Q
PRIVATE DISPOSAL SYSTEM �7
SEPTIC TANK.SEEP.PIT(S) O
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ F
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[IOWNER'S
Permit $ SEEP.PIT(S)❑ CESSPOOLS❑
AUTHORIZATION I TOTAL FEE I I 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`
OWNEROR
OWNERS AGENT
w N
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY Y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSEDAS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE- 'D"' . x r
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. +�
SIGNATURE _
OF PERMITTEE