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Home My Public Portal About5843-5845 GOLDEN WEST AVE_Sewer__ / Y °_82 76A8A642D APPLICATION FOR PERMIT 842 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING -/, JOHN A. LAMBLE, County Engineer ADDRESS ✓ � WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY BK P(G�r� CONTRACTOR �` 19" .� ADDRE �''16a467,.�, (LIK CONNECTION DATA CITY TEL NO ��l p;�O ATI ON DEPTH R-STATE MANHOLE REFERENCE r UPPER REGISTRATION NO ❑ COUNTY L'010!$W� NO DESCRIPTION OF WORK FEET OF CO N LENGTH FROM HOUSE SEWER CONNECTING TO Y ��P L ML TO P L O PUBLIC SEWER CC $5 00 PC NO SEPTIC TANK,SEEPAGE PIT OR V PITS AND/OR DRAINFIELD @ $1000 CO IMP NO .108 NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO A PRIVATE DISPOSAL SYSTEM @ S3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE W WORK TO HOUSE SEWER @ S300 IYYYaLJJJ OVERFLOW SEEPAGE PIT DRAINFIELD (n EXTN C ESSPOOL,DRYWELL MANHOLE @ $500 Z ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 21 00 CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THEHEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP,PIT(S) 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'REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE AB DESCRIBED RESI NTIAL ROPERTY ABANDON HOUSE SEWER SIGNATURE OF PERM ITTE BACKFILL SEPTIC TANKS El SEEP,PIT(S) ElCESSPOOLS ❑ VALIDATION ROBERT A. WOOD M O CASH SUPERVISING MECHANICAL ENGINEER i nt�o3 o:1; FEB 71c-) 0 7.0 O M 6A642 D°'82 7APPLICATION FOR PERMIT S 78A 842 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ✓� /,� JOHN A. LAMBIE, County Engineer ADDRESS n !� WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST of LEGAL DESCRIPTION LOT NO OWNER �l/-�✓ ��—r � / BLOCK TRACT !/iFs' MAIL ADDRESS NO OF BLDG tp, SIZE OF LOT NOW ON LOT CITY - TEL NOUSE OFDISTRICT NO GROUP MAP SED BY BUILDINGS PG BK CONTRACTOR � ADDRESS(? J CONNECTION DATA CITY TEL NO 5 ATION DEPTH / STATE MANHOLE REF � T UPPER REGISTRATION NO (Q COUNTY r• G• NO DESCRIPTION OF WORK FEE TYPE OF CONN T LENGTH FROM d HOUSE SEWER CONNECTING TO Y C L ML TO P L O PUBLIC SEWER @ $5 00P C NO V SEPTIC TANK,SEEPAGE PIT OR CO IMP NO - JOB NO PITS AND/OR DRA INFIELD @ $1000 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NOO PRIVATE DISPOSAL SYSTEM @ $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE {JJ WORK TO HOUSE SEWER @ $300 0- OVERFLOW OVERFLOW SEEPAGE PIT DRAINFIELD V) EXTN,CESSPOOL,DRYW ELL,M!j NbtpLE @ $500 Z ALTER REPAIR OR ABANDO SE HWY OR ST WIDENING SEWER O DISPOSAL S @ 3300 STATE EN CROACHM T PERMIT NO �� 1 INDUSTRIAL WASTE APPROVAL OWNERCHARGES S PERMIT $ AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLISEWER APPROVALS DATE INSP CTOR S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER (/� OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP PIT(5) 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 L MBING AND SEWERS CESSPOOL ❑ DRYWELL ❑HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFSEWAGE DISPOSAL SYSTEM IFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND IDE IN, THE ABOVE DESCRIBED RESIDENTIA PROPERTYABANDON HOUSE SEWER NATURE BACKFILL SEPTIC TANKSF PERMITT SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH ' L'to 5 3 4 9 FEB 7 1 1 U 2 5.0 0, V