HomeMy Public PortalAbout5709 GOLDEN WEST AVE_Sewer__ SaE-6311.55 APPLICATION LICA Y 'ION FO! l ,�E0'�MIT -J,70 • 4 0
DIVISION- OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS 6L
® yCASSATT D GRIFFIN, SUP r of BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST -
LEGAL
DESCRIPTION J-/ OWNER LOT NO (p(J \:
BLOCK �/— TRACT MAIL
J b ADDRESS D
NO. OF BLDGS CITY G� TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS , DISTRICT NO I GROUP MAP
Y BK - PG _
CONTRACTOR
t > CONNECTION DATA .
ADDRESS
CITY NO STATION DEPTH� � -
_ rrff MANHOLE REFERENCE `
6r �_t El STATE _ !{ OWER
REGISTRATION NO ""�� "❑ 'COUNTY, —" � `�-"` +"'�""''-' 01
- —"-^'
No, DESCRIPTION OF WORK V FEE
HOUSE SEWER CONNECTING TO - Y TYPE OF CURB TYONP L METH L GTO p OMS
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR `�� '
ITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELDP C NO.
- -
EXTN .CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $100 TRUNK PERMIT NO ROAD PERMIT NO EJ
/ CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT ,
WORK TO HOUSE SEWER @ $1 00 C li PERMIT NO _
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEIIMIT t 00
AUTHORIZATION I' TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECT R'S SIGNATURE
TRACTOR TO CONNECT THE 'ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW I. / J NEW HOUSE SEWER
SIGNED THIS DAY OF ( � l9-" CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS-2i"� I 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 tiAND/OR AND
DISCONNECT PLUG
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
WER
DESCRIBED RESIDENT PERTY , BACKFILL SEPTIC TANKS❑
SIGNATURE - a I! SEEP PIT(S) ❑ CESSPOOLS[•}�
OF PERMITTEE Vii• '.f�. f
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD,CHIEF PLBG INSPECTOR
CK. Id 0.
ASH S