HomeMy Public PortalAbout5819 GOLDEN WEST AVE_Sewer__ 7 6 A E-663 12.54 D
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5& PPL C A T I ON •'.■ O PERMIT
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DIVISION OF BUILDING AND SAFETY S EW E R-S SWAG E DISPOSAL
--'Depcatment of County Engineer
County of Los Angeles Bu1LDING
WM. J. FOX, COUNTY ENGINEER ADDRESS ® �� ZQ
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY /
FOR APPLICANT TO FILL IN NEAREST '
_CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT D AMAIL
DDRESS
NO. OF BLDGS. 0
-
SIZE OF LOT , NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS - �-a. Q. DISTRICT N0. GROUP MAP
,MBK PG
CONTRACTOR
ADDRESS CONNECTION DATA 4
TEL. N rlZ ;Z .. STATION
DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY c� J UPPER .
TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE cY z. 026 P.L. M.L.TO P.L. �l
/I HOUSE SEWER CONNECTING TO - �11� fZ� :1�
PUBLIC SEWER n $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR -
WORK TO HOUSE SEWER 1.00 G.. CO. IMP. NO. �t✓i - 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 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
.SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
- o
_ I AVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING/ APPROVALS DATE IN PECTOR S SIG
HNATURE
TO THE PUBLIC S'
SIGNED THIS DAY 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL �r
OWNERS GE BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRES /� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION CESSPOOL I—] DRYWELL[IAND 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 LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER THE ABOVE —
DESCRIBED RESIDENTIAL P OPERTY. BACKFILL SEPTIC TANKS❑ � (q
SEEP. PITS) ❑ CESSPOOLS 'T"�'QS' i• "' a.._
SIGNATURE /fie
OF PERMITT : °^`(
WILLIAM J. FOX,Cou NGINEER VIA ATION
AC0 7 1 9 8 AUG 2 6 4 5.5 U to
BY BY
DEPUTY DEPUTY
BY BY
® DEPUTY DEPUTY