HomeMy Public PortalAbout5703 GOLDEN WEST AVE_Sewer__ c iT y ® " �/1GlP,L C �Ty
762
78A642D APPLICATION FOR PERMIT
42D lJ
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
JOHN A. LAMBIE, County Engineer ADDRESS Q�
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO ,FILL IN cRoSB 5T�/r
LEGAL O
DESCRIPTION LOT NO OWNER ��.-�j,•
BLOCK TRACT 4 6-6 /(/4/113 7Z-34 z3s MAIL
ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE I _ ���
[BUILDNGS DISTRICT NO GROUP MAP PROCESSED BY
/� BK PG
CONTRACTOR ��� �� �Q E , _
ADDRESS , ` �� (�Y CONNECTION DATA
CIT • �� �• TEL NO �. STATION DEPTH
t STATE MANHOLE REFERENCE UPPER
REGISTRATION NO / ({% �G'�`^ ❑ 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 4
PUBLIC SEWER @ $5 00 PC NO v
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO V
PITS AND/OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ 5300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVEM I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL,DRYWELL MANHOLE @ $5 00N�j-
HW OR ST WIDENING b
,.. _::111)
.;ABANDON HOUSE goo DISPOSAL SYSTEM @ $300 OO STATE E ROACHMENT
J PERMIT N
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $1 21 00 CHARGES
CONNECTIO ARGE FEE
AUTHORIZATION I TOTAL FEE
ITHAVE AT THIS DATE A CONTRACT WIH THE HEREIN NAMED CON REI URSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP,PIT(S)
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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR \
LICENSEDAS 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 ABOV ESI.RIBED R IDENTIAL PROPERTY
ABANDON HOUSE SEWER _
SIOF APERMTUR ITTEE BACKFILL SEPTIC TANKS ❑ O
SEEP,PIT(S) ❑ CESSPOOLS YJ
VALIDATION ROBERT]
GM o cgsH SUPERVISING MECHANICAL ENGINEER
L;Co 0 2 2 9:u JAN 2 5 1 (0 d 5.00—