HomeMy Public PortalAbout5617 GOLDEN WEST AVE_Sewer__ - pp 9l
IS
APPLICATION I N F® PERMIT
1
S&E-669 11.55
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER 17
ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYNEARED�`•-• � ;
FOR APPLICANT TO FILL IN ST.
LEGAL
DESCRIPTION LOT NO. OWNE� �
MAIL
BLOCK TRACT P' � � ADDRESS �� � •�� L,�GF,a9�
NO. OF BLDGS. 9 CITY �! TEL. NO.
SIZE OF LOT NOW ON LOT P!.
USE OF ,,, �J„ „/ DISTRICT NO. GROUP MAP
BUILDINGS /v�'L+ J�
6,�_ PG
CONTRACTOR
ADDRESS - - CONNECTION DATA
a �
/f �y STATION DEPTH
CITY TEL.
NO.�N' ���GY _ \
MANHOLE REFERENCE
1 y '777a STATE LOWER'
REGISTRATION N0. /� ❑ COUNTY
------
N0. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO _ TYPE OFC JCTION LENGTH FROM
,.y Y. C RB P.L. M.L. TO P,L.
® PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO. -
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO. IMP. NO. 4 JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 �,V TRUNK PERMIT NO, ROAD PERMIT NO. (�
j CONNECT ADDITIONAL BLDG.OR / ®� STATE ENCROACHMENT
® WORK TO HOUSE SEWER @ $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 $ 1 �00
AUTHORIZATION TOTAL FEE 1r V REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- lia - .. .APPROVALS PATE IN PECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING f
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT ��J"> -+?J �m• its.-�
- SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT 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 THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURESEEP.PITS) ❑ CESSPOOLS ( Cc> _.�y ,,,.M1.w�-fdr"�•
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER �SVALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
�A M.0. CASH '