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Home My Public Portal About5612 GOLDEN WEST AVE_Sewer__ A642D,2-eg 76 "6 A APPLICATION ION FOR PERMIT 78A COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER _ BUILDING AND SAFETY DIVISION BUILDING n JOHN A. LAMBIE. COUNTY ENGINEER ADDRE58� COLEMAN W JENKINS. SUPT OF BUILDING ` 2 LOCALITY NEAREST FOR APPLICANT TO FILL IN CROBS sT LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADDRESSNOF SIZE OF LOT NOWOON LOTS Q CITY •, TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY BK PG CONTRACTOR ADDRESS CONNECTI N DATA CITYda TEL NO A STATION DEPTH STATE LIC i UPPER LICENSE NO CLASS MANHOLE REFERENCE OWER NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM / HOUSE SEWER CONNECTING TO Y PL M L TOIL PUBLIC SEWER @ $S 00 SEPTIC TANK SEEPAGE PIT OR J C NO r PITS AND/OR DRAINFIELD @ $1000 CO IMP NO ; OB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / r PRIVATE DISPOSAL SYSTEM ® $3 00 D- CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIYEE I EASEMENT RECORD INSTR NODATE C) WORK TO HOUSE SEWER Q $300 OVERFLOW SEEPAGE PIT DRAINFIELD Q= E XTN CESSPOOL DRYWELL MANHOLE @ $500 HWY OR ST WIDENING �R ABANDON HOUSE U SEWER OR DISPOSAL SYSTEM 0 $300 Lu STATE ENCROACHMENT CL PERMIT NO C/) Z INDUSTRIAL WASTE APPROVAL OWNER'S PERMIT s z 00 CHARGES AUTHORIZATION LTOTAL F'EE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED VCON. REIMBURSEMENT-FEE TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTI IG DWELLING TO THE PUBLIC 5 TO TH E PU BL'C ! APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS � Y OF I OWNER OR NEW HOUSE SEWER OWNERS AGENT / CONNECT ADDITIONAL �G` S BUILDING OR WORK ADDRESS SND/OR ANA SEEP,PIT(3) I HEREBY ACKNOWLEDGE THAT I HAVE!'READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS ` CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL S YSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOV DESC*LBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER {p SIGNATURE OF PERMITTEE X& BACKFILL SEPTIC TANKS ❑ SEEP PIT(S) ❑ CESSPOOLS ❑ 6 AUDATION JACK R. ALLEN /�C�K// M O CASH SUPERVISING MECHANICAL ENGINEER 9 5 6 C6 APR 2 4 0 D cj Q Q CEA°8 '-65 76A 642D APPLICA ION FOR PER IT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION TADDRESS UILDING JOfIN A LA\IRIE County h,ngmeer COLE, M1 W JN.NKINS, Sup't of Building OCALITYEAREFOR APPLICANT TO FILL INRDSS BT ^ LEGAL DESCRIPTION LOT NO S^ OWNER 3 MAIL BLOCK TRACT ADDRESS l/t7 NO OF BLDGS SIZE OF LOT NOW ON LOT CIT TEL NO USE OF DISTRICT NO GROUP MAP PROCESSED BY BUILDINGS K PG CONTRACTOR �v ADDRESS t CONNECTION DATA CITY NOSTATION DEPTH / LICENSEE NSE !7 UP ER NO 3 79 LASS ,�. MANHOLE REFERENCE OWER NO ESCRIPTION OF WORK E TYPE OFC CTION LENGTH FROM / HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L PUBLIC SEWER @ $ 5 00 d SEPT[ TANK SEEPAGE PIT R J C NO PITS AND/OR DRAINFI". C $10 00 CO IMP NO ` � OB NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V PRIVATE DISPOSAL SYSTEM C $ 3 00 p[ CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE IZ_ WORK TO HOUSE SEWER @ $ 3 00 REPAIR E A AB ND N HOUSE V SEWER OR DISPOSAL SYST FM C $ 3 00 l!J HWY ORST WIDENING d E%TN ,CESSPOOL, MANHOLE @ $ 5 00 STATE ENCROACHMENT z PERCOLATION TEST @ $ 5 00 PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMTT s 2 00 AUTHORIZATION I TOTAL FEE 0 CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED rrrTING DWELLING APPROVALS TO THE PUBLIC SEWER DATE INSPE OR S SIGN TURE SIGNED THISY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT ' CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP,PIT(S) IH ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL [I DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED S REQUIRED BY LO GLES COUNTY AND STATE OF EWAGE DI SPOSAL SYSTEM CALIFO I OR T A T L AL OWNER OF AND INTEND TO DISCONNECT PLUG AND *ESI I THE OVE DES/ IB RESIDE TIAL P TY ABANDON HOUSE SEW ER SI r ACKFI LL SEPTIC TANKS F PE ❑ T IT fS) ❑ CESSPOOLS C] VAL115ATION CK m oASH