HomeMy Public PortalAbout5429 GOLDEN WEST AVE_Sewer__ 76A642D 5
CE 808(REV.6/78) APPLICATION FOR PERMIT
®s
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP BN 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 BLOCS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR -� - 1 INDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEECL
STATE LIC. REIMBURSEMENT FEE O
LICENSE NO. y �.(,.;'_;- CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS W
DATE INSPECTOR'S SIGNATURE J
HOUSE SEWER CONNECTING TO LL.
PUBLIC SEWER
NEW HOUSE SEWER A'
SEPTIC TANK,SEEPAGE PIT OR IIX
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
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
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ W
EXTN..CESSPOOL.DRYWELL,MANHOLE H
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 F3OWNER'S
Permit S SEEP,PIT(S)❑ 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
TOTHE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNEROR
OWNERS AGENT
ADDRESS
1 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
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. I
SIGNATURE
OF PERMITTEE