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HomeMy Public PortalAbout5420 GOLDEN WEST AVE_Sewer__ CE 08E808(REV.6/78) REV.6/78) APPLICATION FOR PERMIT ©5 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 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. CITY TEL.NO. CO.IMP.NO. JOB NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT � r 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 CITU TEL.NO. CONNECTION CHARGE FEE /Q STATE _ LIC. REIMBURSEMENT FEE ~ LICENSE NO. - ` CLASS V NO. DESCRIPTION OF WORK FEEW APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO PUBLIC SEWER t NEW HOUSE SEWER .. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM O SEPTIC TANK,SEEP,PIT(S) CONNECT ADDITIONAL BLDG.OR4,. WORK TO HOUSE SEWER AND/OR DRAINFIE LD OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ W 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 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_ OWNEROR OWNERS AGENT ADDRESS yt ^ 4 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY d ^• '. 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 1 AM THE LEGAL OWNER OF,AND INTEND TO RE- SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. SIGNATURE OF PERMITTEE