HomeMy Public PortalAbout5718 GOLDEN WEST AVE_Sewer__ S&E-66311.55 APPLICATION FOR PERMIT 1
DIVISION OF. BUILDING AND-SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING 1
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUP T of BUILDING - LOCALITYNEAREST
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FOR APPLI ANT TO FILL,IN CROSS ST. 'ea z5:7
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LEGAL ''—
DESCRIPTION LOT NO y�/` OWNER
MAIL -
BLOCK TRACT ADDRESS
'170. OF BLDGS CITY _ TEL NO
SIZE OF LOT NOW ON LOT -
USE OF r,
BUIDISTRICT NO GROUP ' MAP
LDINGS, '
BK PG
CONTRACTOR 417
ADDRESS Vol COQN.NECTION DATA
STATION Q � DEPTH
CI TEL. N0. _ UPPER
MANHOLE REFERENCE �
❑ STATE
REGISTR TION NO (Jr ❑ COUNTY
No. DESCRIPTI NOF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF 'TION' LENGTH FROM "�
PUBLIC SEWER @- $3 50 Y. URB P L M L TO P L '�\
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT,DRAINFIELD O P. C.-NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO '`"}} JOB NOHOUSE SEER
'
PR VATE DISPOSAL SYSTEMG TO @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER @ $i 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE I INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE _
OWNER'S PERMIT a 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED coN- APPROVALS DATE IN SPECTOR'S SIGNATURE '
TRACTOR TO CONNE T THE ABOVE DESCRIBED EXISTING DWELLING r
TO THE PUBLIC SE ,,,,�-���• NEW HOUSE SEWER'
SIGNED THIS DAY OF 1�G�G CONNECT ADDITIONAL,
OWNER OR BUILDING OR WORK -
OWNERS AGENT 'SEPTIC TANK,SEEP, PIT(S) -
ADDRESSAND/OR DRAINFIELD'
I HEREBY'ACKNOWLEDGE THAT HAVE READ THIS APPLICATION •CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS 6ORRECT 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 AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF_ ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LE L OWNER OF THE ABOVE
DESCRIBED RESIDENTPROPERTY- BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) [I CESSPOOL D r
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD. CHIEF PLBG. INSPECTOR
CK. Y 0. CASH
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