HomeMy Public PortalAbout5728 GOLDEN WEST AVE_Sewer__ 76A6421)
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808(REV 6/781 ` APPLICATIOM*FOR PERMIT' .
_
SEWER -1 SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND'SAFETY" -j"', '}
FOR APPLICANT TO FILL-IN' DISTRICT NO GROUP "•`.,MAP I OCESSED BY+ - '
BK �- PG
BUILDING /y^� -
ADDRESS {J x N. .t.T u" •!
��• _ CONNECTION DATA'
LOCALITY
NEAREST STATIONROSS ST 'TL 'DEPTH -
+e b4"-BR
MANHOLE REFERENCE lJ-I
LOWER
OWNER /llL TYPE OF COfyIN�G^TION - LENGTH FROM � �-+
MAIL Y Rp1,{ B� P IL M L TO P L �,--7
ADDRESS —7 8, �' .ff „
_ /� /6
TG NO
J
CO IMP NO OB NO
CI EL NO
LEGAL TRUNK PERMIT NO' l• ROAD PERMIT NO 912 V O J
DESCRIPTION LOT NO 41
AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE 1 _
BLOCK TRACT
' NO OF BLDGS - - - --)'
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING +
1.
USE OF
BUILDINGS .rlq. ° STATEENCROACHMENT \
PERMIT NO
INDUSTRIAL
CONTRACTOR' /"/l �, WASTE APPROVAL
ADDRESS ..Z vr�y CHARGES
CITY TEL NO J _ J 8g CONNECTION CHARGE FEE ,
STATELIC REIMBURSEMENT FEE
LICENSE NO j"-�� 6 CLASS
NO DESCRIPTION OF WORK FEE APPROVALS DATE IN A CTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER, I-
SEPTIC TANK”SEEPAGE PIT OR .- NEW HOUSE SEWER 2
PRS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR SEPTICTANK SEEP PIT(S)AND/OR DRAINFIEL
WORKTO HOUSE SEWER O -
OVERFLOW SEEPAGE PIT DRAINFIELD - CESSPOOL,❑ DRYWELL❑
EXTN CESSPOOL,DRYWELL,'MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER REPAIR,SEWER OR -
SEWER OR DISPOSAL SYSTEMSEWAGE DISPOSAL SYSTEM s� '
DISCONNECT PLUG AND »'
+ ABANDON HOUSE SEWER
_ .BACKFILL SEPTIC TANKS❑ - - - - - -
OWNER'S
PefRl IF '$ SEEP PIT(S)❑ CESSPOOLS[I
AUTHORIZATION` ' TOTAL FEE VALIDATION
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I HAVE AT„THIS DATE.A CONTRACT WITH THE HEREIN.NAMEO CON-
TRACTOR TO CONNECT,THE ABOVE DESCRIBED EXISTING DWELLING �/
TO THE PUBLIC SEWER - W � /y
SIGIJEDTHIS DAY OF' - - 19= 1'Z:dO.�i� �' vi�� - �' � tJ5 T'1
OWNER OR •.
v`
OWNERS AGENT - , ”
'ADDRESS tt
I HEREBY ACKNOWLEDGE THAT 1 HAVE-READ THIS APPLICATION "- �2 O'O'1 a O 0
AND STATE THAT-THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING 8,00-5
PLUMBING AND SEWERS -- - - ^ • - -- - O Wo 1
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR I
LICENSED AS,REOUIRED BY LOS ANGELES COUNTY AND STATE OF + '
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTENDTO RE- 4i�- _ _ _ _Q h /I 7.O
O � ,.
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY !t I J
SIGNATURE,-OF PERMITTEE