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HomeMy Public PortalAbout5441 GOLDEN WEST AVE_Sewer__��T T�� 76A642D " CE 80 8IREV.6/781op s 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 CONNECTION DATA LOCALITY 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 TRAGI 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 CONNECTION CHARGE FEE CITY TEL.NO. STATE LIC. REIMBURSEMENT FEE Ou LICENSE NO. CLASS NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSP CTOR'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 O SEPTIC TANK,SEEP,PIT(S) CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD a WORK TO HOUSE SEWER 2 OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL E DRYWELLQ' uj 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 Permit S SEEP,PIT(S)OWNER'S Q' CESSPOOLS Ell AUTHORIZATION 1 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_ 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 ��' s Y '. 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 I AM THE LEGAL OWNER OF.AND INTEND TO RE- SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. SIGNATURE OF PERMITTEE