HomeMy Public PortalAbout5603 GOLDEN WEST AVE_Sewer__ D
CE80S APPLICATION FOR PERMIT
E808 11-57 COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FDING
JOHN A. LAMBIE, County Engineer ESSCASSATP D. GRIFFIN, Sup't of Building LITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. f
LEGAL
DESCRIPTION LOT NO. �� - OWNER _
BLOCK TRACT - / MAIL
ADDRESS
NO.OF BLDGS. '
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS M DISTRICT NO. I MGROUP I MAP
BK PG
CONTRACTOR -
ADDRESS CONNECTION DATA
CITY - - TEL. N0. STATION DEPTH
STATE. MANHOLE REFERENCE UPPER
REGISTRATION NO. H COUNTY LOWER
NO. DESCRIPTION OF WORK -FEE
f HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.5Q,
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P. C. N0.
PRIVATE DISPOSAL SYSTEM @ $1,00 CO, IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.: - ..
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. J_
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)/
AND/OR DRAINFIELD
I 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALI-I ORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE (.' SEEP. PIT(S) ❑ CESSPOOLS ❑
OF PERMITT F r
OF VALIDATION ROBERT A. WOOD
CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
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