HomeMy Public PortalAbout5717 GOLDEN WEST AVE_Sewer__ 24650 INSERTS
76AS42D80
APPLICATION FOR PERMI"I"°..
COUNTY OF LOS ANGELESSEWER—SEWAGE DISPOSAL ! ��
DEPARTMENT OF COUNTY ENGINEER BUILDING �^
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County Engineer Ct`
WILLIAM A. JENSEN, Sup'! of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. -
LEGAC -
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL ,
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY TEL_NO.
USE OF
�BUILDf DISTRICT NO. GROUP MAP PROCESSED BY
PG ,
CONTRACT �;� � �
ADDRESS , CONNECTION-DATA-
CITY TEL NO 10N DEPTH
��
STATE MANHOLE REFERENCE
REGISTRATION N0. � COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO '
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION - LENGTH FROMSEPTIC
•�7 i
PITS AND/OR DRAENFGELDT OR @ $3 00 Y. qP
CURB .L. M.L.TO P.L.
OVERFLOW•SEEPAGE PIT, DRAINFIELD -
EXTN CESSPOOL DRYWELL @ $2 00 -
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 'CO IMP.NO. ? JOB NO. i
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 .TRUNK PERMIT NO. .ROAD PERMIT NO. '� Q
U
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER DISPO AL S M @ $1000:N0. 0:
,INDUSTRIAL
WASTE APPROVAL W
CHARGES taA
OVVNER'S PERNJJT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE'HEREIN NAMED CON-
TRACTOR TO CONNECT-THE ABOVE DESCRIBED EXISTING DWELLING • ' APPROVALS , DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
-OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
HEREBY''ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - -- - -- - -
AND STATE' THAT THE.ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑ - <
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-
CALIFORNIA
LICENSED AS REQ RED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER.
CALIFORNIA AT 1 AM THE LEG "OWNS F THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED. NTIAL PROPERTY. MEP:PITS) ❑ CES OO LS, '
SIGNATU
OF PE /2
®� VALIDA'TIO ROBERT'A. WOOD
CIL M.o. CASR SUPERVISING MECHANICAL ENGINEER
L4 a I U
s
A
24650 INS TS '
�CE8088.80 APPLI0�TI®N
- FOR PERM-M
�aneazo COUNTY OF LOS ANGELES SEWER•-SEWAGE DISPOSAL_ .
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION' BUILDING
- .ADDRESS' r -
JOHN A. LAMBIE,•County Engineer
WILLIAM A. JENSEN, Supt of Building ,LOCALITY r
NEAREST
FOR APPLICANT TO FILL IN caoss sr.
FBUILDINGS
` 'OWNER
ON LOT N0. -
TRACT MAIL '
ADDRESS
NO OF BLDGS. " -
T NOW ON LOT CITY TEL NO.
DISTRICT NO. GROUP MAP PROCESS BY- S `A /I rrgK _PG
CONTRACTOR ,S V'• _`lr, v - J `
ADDRESS .� CONNECTION�DATA
CITY , TEL NO. .ST N / DEPTH
ii
STATE MANHOLE REFERENCE •G UPPER
REGISTRATION NO. `�►jQy COUNTY
NO DESCRIPTION OF WORK FEE - _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 dJJ
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB - M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00 _ -
OVERFLOW SEEPAGE PIT DRAINFIELD r
EXTN CESSPOOL DRYWELL @ $2 00 '
HOUSE SEWER CONNECTING TO - - P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG OR I TRUNK PERMIT NOROAD PERMIT NO. 'l � U - '
WORK TO HOUSE SEWER @ $1 00 v
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00PERMIT N0. '-
O
-INDUSTRIAL
WASTE APPROVAL Wt
` CHARGES ttoo
OWNER'S PERMIT S T 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS '(DdTE INSPEC;LOR�;S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS �—DR-A X I9= NEW HOUSE SEWER /1d1W-
OWNER OR CONNECT ADDITIONAL t ` r
OWNERS AGENT - BUILDING OR WORK t -
ADDRE59 - SEPTIC TANK,SEEP.PIT(S) ,
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION - - - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ '�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED, AS EQ D BY LOS ANGELES COUNT AND STATE OF. ABANDON CT PLUGHOUSE'SAND
CALIFORNIA AT 1 AM THE LE L OWN OF THE ABOVE
DESCRIBE NTIAL PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNAT SE PIT(S) ESSPOOLS `
OF P ITT
®� VALIDATION ROBERT.A. WOOD
CK. M.o.. cABH - SUPERVISING MECHANICAL,ENGINEER