HomeMy Public PortalAbout5423 GOLDEN WEST AVE_Sewer__ 76A642D
CE8081REV.6/78i APPLICATION FOR PERMIT
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
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.
CIRY TEL.NO.
LEGAL TRUNK PERMIT NO, ROAD PERMIT NO.
DESCRIPTION LOT NO.
BLOCK TRACT j w
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
CITU TEL.NO. CONNECTION CHARGE FEE d
STATE LIC. ,. REIMBURSEMENT FEE O
LICENSE NO. CLASS u
NO. DESCRIPTION OF WORK FEEW
APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S) O
AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL E] DRYWELL[I LuEXTN..CESSPOOL.DRYWELL,M ANHOLE Lu
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❑
OWNERS Permits SEEP,PIT(S)❑ CESSPOOLS❑
AUTHORIZATION r TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER.
SIGNED THIS DAY OF 19
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY 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 A:
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