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Home My Public Portal About5626 GOLDEN WEST AVE_Sewer__ CE8083-82 78A842D APPLICATION FOR PERMIT , COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS neer WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FML IN CROSS ST LEGAL DESCRIPTION LOT NO 117 OWNER MAIL BLOCK TRACT f ADDRESS NO OF BL DGS SIZE OF LOTY I& NOW ON LOT CITY TEL NO USE OF DISTRICT NO GROUP MAP PROCESSED BY BUILDINGS BK PG I N CONTRACTORLf ADDRESS _ CONNECTION DATA f CITY TEL NO STATION DEPTH LLUXX� l STATE UPPER REGISTRATION NO �/ COUNTY MANHOLE REFERENCE LOWER NO DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM HOUSE SEWER CONNECTING TO Y U B P L ML TO P L PUBLIC SEWER n0 E5 00 P C NO v SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO V PITS AND/OR DR INFIELD @ $10 00 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO f _/ PRIVATE DISPOSAL SYSTEM @ $3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT wmVER EIISCMENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2Fat CONNECTION CHARGE FEE CHARGES AUTHORIZATION TOTAL 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 SEWER APPROVALS DATE l INSPECTOR'S SIG7ATURE SIGNED THIS - DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL t _ BUILDING OR WORK ADDRESS SEPTICTANK SEEP, PIT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE 15 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 REOUIRED BY LOS ANGLES COUNTY AND STATE OF S EW AGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABO DESC IBED R DENTIAL PROPERTY ABANDON HOUSE SEWER LlG F ERMITTE NATURE BACKFILL SEPTIC TANKS ❑ OPE SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH .S'9'"5t 6th Au615 1 0 D 7.0 ON -62 76A642D APPLICATION FOR PERMIT,_' - �-� 6A642I.I COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER -BUILDING AND SAFETY DIVISION BUILDING ` ' JOHN A. LAMBIE, County Engineer ADDRESS �(/� L Q�jV WC S WILLIAM A. JENSEN, Sup't of Building LOCALITY Ary, [� NEAREST FOR APPLICANT TO FILL IN CRD55 5T - LEGAL e DESCRIPTION LOT NO OWNER J MAIL BLOCK TRACT ` -�3 ( ADDRESS NO OF SLOGS SIZE OF LOT NOW ON LOT CITY EL NO USE OF BUILDINGS DISTRICT NO GROUP MAPESS ED BY BK PPF3j1[� G � ✓\ CONTRACTOR ADDRESS 173 g-7- 4 ' CONNECTION DATA CITY AjTEL NO /, STATION DEPTH I�+1 STATE MANHOLE REFERENCE UPPER REGISTRATION NO LJ COUNTY LOWER NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L O PUBLIC SEWER @ $5 00 PC NO SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO U PITS AND/OR DRAINFIELD @ 31000 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM ® $300 ONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIYLp EASeMENi RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $3 00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN,CESSPOOL,DRYWELL MANHOLE @ $5 00 ALTER R N HOUSE HWY OR ST WIDENING _ SEWER O ^�rv?ve.r�"�T-==�M $3 00 STATE ENCROACHMENT _ t PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE I J 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 SEWER APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER ORr NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS 7 SEPTIC TANK.SEEP PIT(S) I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING , PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ Z r1 I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REP_NLR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE_DISP�OSAL�SYSTEM CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DESL IB ED'RESIDENTIA�PRO Y ` ABANDON HOUSE SEWER 1 SIGNATURE BACKFILL SEPTIC TANKS �Ff OF PERMITTEE ' SEEP PIT(S) ❑ CESSPOOLS ❑ /EKfY.frK j VALIDATION ROBERT A. WOOD cK M o cnsH SUPERVISING MECHANICAL ENGINEER LALO 6 4 5 2 jUN 1 9 1 0 0 5 0