HomeMy Public PortalAbout5719 GOLDEN WEST AVE_Sewer__ 24650 INSERTS"
- 6A642.80
7APPLICATION FOR• PERMIT _
epeazn COUNTY OF LOS ANGELES SEWER-S,EWA1GE ,DISPOSAL .
"DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING'AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Buildmg LOCALITY'
NEAREST 't
- FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ,OWNER'
DESCRIPTION LOT NO. - _
BLOCK TRACT 'MAIL
•ADDRESS
NO OF BLDGS. - .•
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF • DISTRICT N0. GROUP
BUILDINGSMAP PROCESSED Y
1 - PG I
CONTRACTOR -J V v
ADDRESSCONNECTIQTJ)DATA
CITY TEL N S T N ,`DEPTH4F Y
-
STATE pNHOLE REFERENCE
REGISTRATION NO. B COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ,
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION - LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @-S3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 /}
f HOUSE'SEWER CONNECTING TO 'C0.IMP. N0. V JOB N O
PRIVATE DISPOSAL SYSTEM @ $1 00
CONNECT ADDITIONAL BLDG.OR @ $t 00 TRUNK PERMIT NO. ROAD PERMIT NO. U
WORK T&HOUSE SEWER
ALTER,
REPAIR
R ABANDON SYSTEM HOUSE, @ $1 00 - STATE ENCROACHMENT
PERMIT NO O
'INDUSTRIAL " U
WASTE APPROVAL µ7
CHARGES tad
OWNER'S PERNIIT ` $ Z0}0./� CONNECTION CHARGE FEE 4
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE f
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATEl INSPECTOR'S�8IGNATURE,
TO THE PUBLIC SEWER. f
SIGNED THIS Y F J9_ NEW-HOUSE SEWER 1 � -2/07,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK- '!
ADDRESS - SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY 'ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION - - ,•
AND STATE THAT THE ABOVE IS.CORRECT AND'AGREE TO 'COMPLY CESSPOOL ❑ DRYWELL ❑ '
WITH-ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUI LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T AM THE LEGAL NER 0 THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED REST L PROPERTY. _ -
SIGNATURE S P. PIT S CESSPOOLS ❑ _ -
OF PERMITT lz
®�
VALIDATION"-, ROBERT A WOOD
CIL _ X.0. GBH SUPERVISING MECHANICAL ENGINEER
t•-
24650 INSERT$
y
••76A642DB0
APPLICATION FOR PERMIT,,,. - ."
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL,
' DEPARTMENT OF COUNTY ENGINEER BUILDING
,'BUILDING AND SAFETY DIVISION ADDRESS
✓ JOHN A. LA IE, County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY' .'.:
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER _
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS. - '
SIZE OF LOT . NOW ON LOT / CITY TEL. N0. '
USE
ELDINGS OF DISTRICT N0. GROUP MAP PROCES BY F
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL.N0. ��� `L. ON (� DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. S - COUNTY o NO. ..DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION 'LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. C RB 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 `7 P.C.N0. -
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. JOB NO.
. CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @ $1 00 U
SEWER, RR D 3P SAL SYNDON HOUSE @ $1 00 STATE ENCROACHMENTW.
PERMIT NO O
INDUSTRIAL
- - _ WASTE APPROVAL rye,
CHARGES d°1
CONNECTION CHARGE FEE r4
OWNER'S • PERMIT E •
AUTHORIZATION TOTAL FEE t' V REIMBURSEMENT FEE, t.
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS - DATE INSPECTOR'S S1,91NATURE
TO THE PUBLIC SEWER.
SIGNED THIS 19_ NEW-HOUSE SEWER )�9! {JYd �•' i Yfi "
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK - -
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE -THAT 1 HAVE READ-THIS APPLICATION -- - - • •-+ '
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑ _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWE SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTI HAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RE ED BY LOS ANG ES COUNT AND STATE OF ABANDON HOUSE SEWER - -
CALIFORNIA AT 1 AM THE - AWOWOF THE ABOVE `
DESCRIBED, NT1AL PROPERTY BACKFI LL SEPTIC TANKS ❑ -
.SEEP PIT(S).❑ ESSPOO ❑
,SIGNATUR - _ - --- '
OF PE
r
®� VALMATIO Ro ERT_A. WOOD
'CL m.0. cAse SUPERVISING MECHANICAL ENGINEER _
t'.