HomeMy Public PortalAbout5757 GOLDEN WEST AVE_Sewer__ 76AG42D AP®LI■ -ATION { Q \ ■ E to�' IT 9
S&E-663 3.55 ® `Oi
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D!S POSA L
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS ,
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT �® ADDRESS
NO. OF SLOGS.
g
SIZE OF LOT,.. v NOW ON LOT ® CITY —� NO.
USE OFimp
BUILDINGS '�. DISTRICT NO. ROUP MAP
PG
CONTRACTOR � A'.1,z e7�,�/f�i,,/9 r I ;rK+�d
ADDRESS 124&47: !�f CONNECTION DATA
CITY �G/-1� 40 TEL. N0. ��' ����® STATION & '��d, & DEPTH
STAT[ MANHOLE REFERENCE vs� �j 0 Q� UPPER
�1eREGISTRATION N0. //J(T,[ ❑ COUNTY . ! �g � ✓ --
NO. DESCRIPTION OF WORK FEE TYPE v 0 ECTIOIJ LENGTH FROM
a
HOUSE SEWER CONNECTING TO
1c- Y. CURB P.L. M.L. TO P.L.
PUBLIC SEWER @a $ 3.50 -' (1
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. ORP.P. C. NO.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. 61 (i9 JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 _ PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 0 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE �� �`� REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE O THEAABODVE DESCRIBED EXISTINGTHE HEREIN AMED DWELLING APPROVALS DATE INS ECTOR'S SIGNATURE
TO THE PUBLIC.SEWER ty
IF /'— NEW HOUSE SEWER ( I'
SIGNED THISDAYOF 10sd/.
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
•� .tom SEPTIC TANK, SEEP. PIT(S)
ADDRESS
AND/OR DRAINFIELD
I HEREBY ACKNOWLEAE7 THAT 1 AVE 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
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSESEWER
DESCRIBED RESIDE A P OPERTY. _ I
BACKFILL SEPTIC TANKS❑ ]
SIGNATURE /A
- �� SEEP. PITS) ❑ CESSPOOLS
OF PERMITTEE
WILLIAM J.FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR
10 3 �p J raj 4 A