HomeMy Public PortalAbout5452 GOLDEN WEST AVE_Sewer__ 76A642D
CE 808(REV.6/781 APPLICATION FOR PERMIT
Qs
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING BK PG
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY
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,
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INST R.NO. DATE
BLOCK TRACTNO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR - WASTEAPPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE O
LICENSE NO. CLA55 V
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATUR
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT
AL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR
AND/OR DRAINFIELD
WORK TO HOUSE SEWER C�
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ W
EXTN.,CESSPOOL.DRYWELL,MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER ORD ISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
Permit SEEP.PIT(S)❑ CESSPOOLS❑
OWNER'S $
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 m k p1 R
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING • a 4 '
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS RE OU IRED BY LOS ANGELES COUNTY AND STATE OF )•.'"" R �"" �'>
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE- '
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE