HomeMy Public PortalAbout5858 GOLDEN WEST AVE_Sewer__ & .66
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APPLICATION . FOR PERMIT"
8 E DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL" --
Deportment of County Engineer /+
COf Angeles BUILDINADDRESS G�'
WM.J.. FO FOX. COUU NTY ENGINEER
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY -
1 0
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT N0. �wS Q OWNER S g oQQ �g Wei
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BLOCK TR�A/CT Ir
/"/ 2 T-f0• qD RAILESS J &�� . '�' ® ®cl a A pW ei 16
SIZE OF LOT /, A ,�„� NOW ON LOTS CITY 4CA& TEL NO.
USE OF
BUILDINGS /P[tsodeg a 0 � Gm..erDISTRICT NO. GROUP MAP
BK PG
CONTRACTOR1 I / pie
ADDRESS W CONNECTION DATA r�
CITY TEL. NO. STATION e 2 ' DEPTH
❑ STATE MANHOLE REFERENCE - (� UPPER
REGISTRATION NO ❑ COUNTY �.d FSR
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE 0 NECTI ON LENGTH FROM
PUBLIC SEWER Q $ 3 50 ^Q UR M.L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 //�
CONNECT ADDITIONAL BLDG. OR
W RI( TO HOUSE SEWER 1.00 �CO IMP NO � OC/J J08 NN
)O
_
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO ('J
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEMA 1.00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 2 00
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S PERMIT � 00 CONNECTION CHARGE FEE
s
AUTHORIZATION TOTAL FEE 0 REIMBURSEMENT FEE
T TO DATE CONNECT THEAABODVEWITH THE HEREIN DESCR BED EXISTINGMED DWELLINGCON-
TRACTOR APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER r
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL v
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRY-WELL❑ -
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES-COUNTY AND STATE OF DISCONNECT PLUG.AND
CALIFORNIA OR THAT I AM THE LEGAL OWR OF THE ABOVE ABANDON HOUSE SEWER I
DESCRIBED RESIDEN L PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS_j
y _�..�,�.►
SIGNATURE
0F,PERMITTEE
W►LLI J.FO .COUNTY ENGINEER VALIDATION f R.A.WOOD. CHIEF PLBG. INSPECTOR
9 8 0 t�_.L'7 t I OV I� '�-1- 4 .50
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