HomeMy Public PortalAbout5920-5922 GOLDEN WEST AVE_Sewer__ E-6D83 11.69
S& APPLICATION FOR PERMIT
S E-6 •
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING - ,01 /J/
'JOHN A. LAMBIE, COUNTY ENGINEER _ADDRESS oC�[i �r�_ K!
T) CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY `
If
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0.
'MAIL -
BLOCK TRACT (jy 'ADDRESS
,(' NO OF BLDGS. CITY TEL. NO.
SIZE OF LOT (/ NOW ON OT
USE OF f �tfl�� DISTRICT NO. GROUP MAP
BUILDINGS � � 8K - , PG
CONTRACTOR
ADDRESS 3 CONNECTION DATA
7 J i// �J/ STATION / �f DEPTH
CITY - L. NO, L Z tr 'MANHOLE REFERENCE UPPER
Ca 91- ATE
REGISTRATION NO. Or lj 3 s-- ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING R TYPE 0 TION • LENGTH FROM /
PUBLIC SEWER @ Y. CURB PL M L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR '
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD P C. NO.
EXTN ,CESSPOOL,DRYWELL,MAN HOLE Q $2 00 CO. IMP. NO. JOB NO
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO, ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER ,Q $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE'FEE
OWNER'S PERMIT $ 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
APPROVALS DATE INSPECTOR SSIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK-
OWNERS'AGENT - SEPTIC TANK,SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD - - -
1 HEREBY ACKNOWLEDGE THAT 1 HAVE 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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
ABANDON DISCONNECT CT PLUG PLUGHOUSE AND
CALIFORNIA OR THAT I AM THE L GAL OWNER OF THE ABOVE -
WER
DESCRIBED RESIDENLUAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOL'S❑
OF PERMITTEE r
Now
JOHN A LAMBIE, COUNTY ENGINEER ALID'ATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK H O CASH - -
W; 3 9 MAS 24-1 0 A 5.00 -N
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