HomeMy Public PortalAbout5829 GOLDEN WEST AVE_Sewer__ CE808-A 4/72 APPLI ATION FOR ERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS L•
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS Sr
LEGAL /I V
DESCRIPTION LOT NO '� ` OWNER V
MAIL
BLOCK TRACT co S / ADDRESS ��(>NO
SIZE OF LOT NOW OON LOTS / CITY TEL NO ti7 ��03
USE OF
BUILDINGS ��� n� DISTRICT NO GROUP MAP PROC ED BY
/�/y T B K P S
CONTRACTOR -
ADDRESS CONN CTION DAT
CITY L^F' MO v-- STATION 3�L-�2 DEPTH
STATE LIC MANHOLE REFERENCE /`_ UPP
LICENSE NO CLASS�� �' 6J__ OWER
NO DES17RIFITICVN OF WORK FEE TYPE OF CONNECTIO LENGTH FROICA
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ /V
SEPTIC TANK SEEPAGE PIT OR I ? Q/ P G NO d
CO IMP NO
PITS AND/OR DRAINFIELD @ �,•J (� .108 NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ _
CONNECT ADDITIONAL BLDG O AFFIDAVIT I WAIYEI I IASEMINT RECORD INS TR NO DATE O
WORK TO HOUSE SEWER I.-
OVERFLOW SEEPAGE PIT DRAINFIELD V '
EXTN CESSPOOL DRYWELL MANHOLE @ uj
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING ��d/l� - C� a
I/ i c/{ to
SEWER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT ` �• 7� ^ Z
PERMIT NO ( '-•Li
INDUSTRIAL
WASTE APPROVAL �'"'-•'--------.�� ^•
CHARGES
OWNERS PERMIT s
CONNECTION CHARGE FEES
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MEO CON REIMBURSEMENT FEE
TRACTOR'To
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR NEW HOUSE SEWER �
OWNERS AGENT
- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 4
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR,
LICENSED AS REO RED BY LOS ANGLES COUNTY A D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT I AM THE LEGAL OWNER OF A D INTEND TO DISCONNECT PLUG AND
RESIDE IN T AB E DESCRIBED RESIDENTIAL P PERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERM T BACKFILL SEPTIC TANKS
SEEP PIT(S) ❑ CESSPOOLS ❑
11Y�
rlK M 0,,TI�C_ i Gc-'C �[>v) CK M 0 CASH -
4 5 3-:DEC 2 1 1 9.5 0