HomeMy Public PortalAbout5611 GOLDEN WEST AVE_Sewer__ L
761342 10-.1
76ae420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Al /
JOHN A. LAMBIE, County Engineer ADDRESS (/J
' WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
[ADDRESS
OR APPLICANT TO FILL IN `ROSS ST
N LOT NO OWNER
TRACT 11131 MAIL ��
ADDRESS
ANO OF BLDGS �+ .7y
OT yy+ NOW ON LOT ! CITY � `�-'T NO
DISTRICT NO GROUP MAP jr�
BK PG -
OR D i•
CONNECSTATION DEPTH'
Af TEL NO
❑ STATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY / LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CTION LENGT FROM ,�.. D.
r HOUSE SEWER CONNECTING TO Y CUR P L M L T F L O
t PUBLIC SEWER @ $5 00 PC NO (J
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO 6 -10B NO
PITS AND/OR DRAINFIELD @ 51000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NV43
PRIVATE DISPOSAL SYSTEM @ $300
l/ Q
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wA1vEq EASEMENT RECORD INSTR-NO DATE LU
TO HOUSE SEWER @ $300 d
OVERFLOW SEEPAGE PIT,DRAINFIELD N
E XTN CESSPOOL DRYWELL,MANHOLE @ $5 00 Z
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS DATE, INSPECTOR' SIGNATU E
SIGNED THIS DAY OF L 19
OWNER ORai - - NEW HOUSE SEWER f `�
OWNERS AGENT
CONNECT ADDITIONAL
lAd'tBUILDING OR WORK l
ADDRESS v SEPTIC TANK SEEP, PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD l
AND STATE THAT THE ABOVE IS-CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR '
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTI PRO
RTY ABANDON HOUSE SEWER
SIGNATURE - ,J,AA ,%/n� BACKFILL SEPTIC TANKS ElOF PERMITTEE J�liYlt- y/ ` SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK M o cgsH SUPERVISING MECHAA NICAL ENGINEER
LG
.9.S• 1 9 o JUN 8 1 0 D •Y O:O O~ 1.17