HomeMy Public PortalAbout5738 GOLDEN WEST AVE_Sewer__ S& -689 11-55 D - APPLICATION FOR PERMIT - 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS (.I�
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN ceoss s T.
LEGAL 6 +` OWNER
DESCRIPTION LOT NO 01
MAIL
BLOCK TRACT ADDRESS
NO F BLDGS CITY TEL NO
SIZE OF LOT - NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS
CONTRACTOR gA 6F BK �G
ADDRESS "p� �C1Al . CONNECTION DATA
I �p STATION DEPTH
CITY TEL NO. -4 G - i
MANHOLE REFERENCE > )
❑ STATE / - LOWER
REGISTRATION NO. COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OFTION LENGTH FROM
-� Y. RB' P L M L. TO P.L
PUBLIC SEWER @ $3.50 _ '
SEPTIC TANK,SEEPAGE PIT OR C
PITS AND/OR DRAINFIELD @ $3 00 '
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. NO. j JOB NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $ 2 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO !6Z�'3
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL c
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERBUT S 1 00
AUTHORIZATION TOTAL FEE .� REIMBURSEMENT FEE - -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS _ DATE 1 PECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE R. NEW HOUSE SEWER
SIGNED THIS— DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK -
OWNERS AGENT
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOSjANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM WE LEGAL (AkVNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY v BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PITS) ❑ CESSPOOLS ( -
OF PERMITTEE '
p'-segmammmy MEMO
JOHN A LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG.JNSPECTOR
cR,+✓ m 0 CASH
',_ACO 6 0 2 2- vAR 14