HomeMy Public PortalAbout5459 GOLDEN WEST AVE_Sewer__ 76A64
CESoa a All ® I iCATI FOR IT
e e sa COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS •�.
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Sup t of Building LOCALITY
-.,.., .-..,.. .. NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. OWNER
BLOCK TRACT Q MAIL
ADDRESS
SIZE OF LOTS 'SX I� NO.OF BL
NOW ON LOT
CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO.a �iRA1fP- MAP ROCESSED BY
BK PG
CONTRACTOR �(�''� -
ADDRESS CONNECTION DATA
CITY EL.NO.
STATION r'i- 1 S DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION 0. COUNTY . / LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
k SEPTIC TANK,SEEPAGE PIT OR TYP CON GTIDN LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD rs
EXTN.. CESSPOOL. DRYWELL @ S2.00 _ /
HOUSE SEWER CONNECTING TOJ-2-76
I_ P.C.NO.
1
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. .� •Q JOB NO.
CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
:y WASTE APPROVAL
CHARGES
€:
OWNER'S PERMIT $ 2 CC CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEEQ ? REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON fl
-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING " APPROVALS DATE 'INSPECTOR;S.SIG NATURE
TO THE PUBLICS ER.
SIGNED THIS DAY OF 19-" NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
s
ADDRESS SEPTIC TANK,SEEP.PITS) _
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
t HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AN ELE COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM T G OWNER OF THE ABOVE
DESCRIBED RESIDE TI L PROP Y. BACKFILL SEPTIC TANKS ❑ -I ?
SIGNATURE
a` + SEEP. PIT(S) ❑ CESSPOOLS ❑ `->`�
OF PERMITTEE
®" ALIDATION ROBERT A. WOOD
CK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
2 1 0 a r U4 3 0 -11 G 5.0
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