HomeMy Public PortalAbout5715 GOLDEN WEST AVE_Sewer__ : 24650 INSERTS•, ,
'CEAPPLICATION , MR PERI IT 1 4
- 78AG42D 842D COUNTY OF LOS ANGELES -SEWER=SEWAfxE _pl-SPbSA,L
DEPARTMENT OF COUNTY ENGINEER
BUILDING el
BUILDING AND SAFETY DIVISION ADDRESS
IOHN A. LAMBIE, Countp Enggineer
WILLIAM A. JENSEN, Supt of Building LOCALITY a
NEAREST r `
FOR APPLICANT T IN CROSS ST.
LEGAL
DESCRIPTION LOT NO, OWNER
BLOCK •TRACT .MAIL'
ADDRESS
NO OF BLDGS. i f,
SIZE OF LOT NOW ON LOT (CITY TEL _NO.'':
BUIOF
LDING , DISTRICT NO. GROUP MAP - PR ESSED BY
I BK PG '
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL N0. STATION DEPTH
STATE•„_ �MANHOLE.REFERENCE— - - ,_ _ _ _ e -
�REGISTRATION H-COUNTY % a
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO "
PUBLIC SEWER @ $3 00 �U .TYPE ONNE ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR ,Y, CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 _
HOUSE SEWER CONNECTING TO l P.C. O.'`
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP N0. 1-3 �l JOB N0.
w
CONNECT ADDITIONAL BLDG OR 'TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER '@ $i 00 V ,
ALTER REPAIR OR ABANDON HOUSE _ STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO p
INDUSTRIAL �+
WASTE APPROVAL W
• CHARGES Va'i
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE v REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIS ING DWEL LNG APPROVALS DATE/ INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. I
SIGNED THIS 11101 NEW HOUSE SEWER
OWNER,OR /' CONNECT ADDITIONAL f /
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
H
EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - --• -
TE THAT THE ABOVE IS CORRECT AND AGREE•TO COMPLY CESSPOOL ❑ DRYWELL ❑LL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPAIR,SEWERORG AND SEWERS. SEWAGE DISPOSAL SYSTEMBY CERTIFY THAT AM PROPERLY REGISTERED,AND/OR DISCONNECT PLUG ANDD AS REQUIRED LOS ANGELES COUN Y AND STATE OFABANDON HOUSE SEWERNIA OR TH AM THE LEGAL OWN OF THE ABOVE BACKFILI'SEPTIC TANKS ❑ p/ / .wED RESID PROPERTY. SEEP PIT(S CESSPOOLS. 47RE MITTE t
®P
VALIDATION ROBERT A. WOOD `
Ca. M.o.. CABH SUPERVISING MECHANICAL ENGINEER
5 13'0--