HomeMy Public PortalAbout5417 GOLDEN WEST AVE_Sewer__ E8081D REV.6/781 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP PG PROCESSED BY
ADDRESS tom^.
CONNECTION DATA
LOCALITYM. '
NEAREST STATION DEPTH
CROSS ST. ,.✓i
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 a
STATE LIC. REIMBURSEMENT FEE 0
LICENSE NO. - CLASS
Lu
NO. DESCRIPTION OF WORK FEE '-
APPROVALS DATE INSPECTOR'S SIG NATUR J_
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG,OR SEPTIC TANK,SEEP,PIT(5) d
WORK TO HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL [jDRYWELL C] W
EXTN..CESSPOOL.DRYWELL,M ANHOLE
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 S SEEP.PITS)❑ 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
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS +. µ
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ,
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY v
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
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 1 AM THE LEGAL OWNER OF.AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE