HomeMy Public PortalAbout5544 GOLDEN WEST AVE_Sewer__ 9.6eD
S fi.eAPPLICATION FOR PERMIT
3& DIVISION OF BUILDING AND SAFETY SEWER SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles FN
ILDING
JOHN A LAMBIE, COUNTY ENGINEER DRESS '
® CASSATT D GRIFFIN, SUPT OF BUILDING CALITY
AREST
FOR APPLICANT T FILL IN OSS ST. ✓�xc/
LEGAL -� —�,. zo
OWNER,
DESCRIPTION LOT N0._ t ... 1` `
MAIL V
BLOCK -TRACT / I / ADDRESS
NO. OF BLDGS - ['` CITY TEL. NO
SIZE OF LOT * Ji�7C,� NOW ON LOT A�
USE OF DISTRICT NO. GROUP MAP
BUILDINGS -
K PG
CONTRACTOR
CONNECTION DATA
ADDRESS ••� _ ! �
TEL. N0. STATION - �Cj DEPTH
MANHOLE REFERENCE _-
-, UPPER , .
,k ❑ STATE
REGIS RATION NO tJ �J ❑ COUNTY
NO DESCRIPTION OF WORK FEE
TYPE OF CTION - LENGTH FROM ,f
HOUSE SEWER CONNECTING TO Y. UR P L M L.TO P.L. �7 '
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELDry P. C. NO, ,
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $ 2 00 ,CO. IMP NO. /;_7 / 1(?. JOB NO ,
HOUSE SEWER CONNECTING TO I
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT N0. - ROAD PERMIT NO. 6
CONNECT ADDITIONAL BLDG OR - 'STATE ENCROACHMENT '
WORK TO HOUSE SEWER 'Q $1 00 PERMIT NO _
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL '
CHARGES
_ 'CONNECTION CHARGE FEE=
OWNER'S PERMIT s t 00
REIMBURSEMENT FEE - -
AUTHORIZATION TOTAL FEE
I HAVE AT,THIS DATE A CONTRACT WITH THE HEREIN AMED CON- APPROVALS DATE INSP CTOR•S SIGNATURE
TRACTOR TO CONNECT THE° BOVE DESCRI ED EXISTING DWELLING
TO THE PUBLIC SW NEW HOUSE SEWER ��S
SIGNED THIS DAY OF 1 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AG T SEPTIC TANK,SEEP,PIT(S)
ADDRESS - Ar AND/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATI N CESSPOOL❑ DRYWELL❑
AND STATE TH4T THE ABOVE IS CORRECT AND AGREE TO COMPLY '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM T EGAL OWNER OF THE ABOVE
' DESCRIBED REST L PR PE Y �BACKFILL SEPTIC TANKS❑ '
SIGNATURE ,r SEEP PIT(S) [_1CESSPOOLS l
V
OF PERMITTEE - '
JOHN A LAMBIE, COUNTY ENGINEER ' VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
sZ 1y CK m O CASH
2 .0 3� Nov 2 6 4