HomeMy Public PortalAbout5924, 5924 1/2, 5926, 5926 1/2 GOLDEN WEST AVE_Sewer__ CE606 3-64 "
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWA ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING —
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't o4 Building
LOCAL
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS L�
SIZE OF LOT NOW ON LOT CITY TEL NO J
USE OF DISTRICT NO 1GROUP MAPPROCESSED BY
BUILDINGS / BK PG
t
CONTRALTO I Q -:om`
ADDRESS ,? �, CONNECTION DATA
TY TEL NO /� STATION DEPTH
TATE MANHOLE REFERENCE UP REGISTRATION NO O/ 2-- COUNTY Uaw.B�
NO DESCRIPTION OF WORK FEE TYPE OF C ION LENGTH FROM
HOUSE SEWER CONNECTING TO D Y CURB P.L. M L.TO P L
PUBLIC SEWER ® $8.00
SEPTIC TANK,SEEPAGE PIT OR P C NO. }
PITS AND/OR DRAINFIELD @ $10 00 CO IMP. NO -108 NO a
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT / O
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIY[[ [A[[M[N7 RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD U
E%TN,CESSPOOL,DRYWELL,MA NH OLE® $B 00 HWY OR ST WIDENING W
ALTER,REPAIR OR ABANDON HOUSE
CL
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT H
PERMIT NO Z
INDUSTRIAL
��}�T� WASTE APPROVAL
O♦.l\LRPERMTf $ 2 OO CHARGES
AUTHORIZACTS ION I TOTAL FEE OD CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTR I REIMBURSEMENT FEE
HE HEREIN NAMED CON-
TOATHERPTO UBLIIC SEECT THE AB VE DEBC I D IST NG WELL
G APPROVALS
DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1
OWNER ORj NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL 1
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(B)
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 T T I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REOUIR BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE GAL OWNER OF, INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DESCR D ESI ENTIAL P ERTY
(/ice ABANDON HOUSE SEWER ry
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ pti J
?/
SEEP,PIT(5) ❑ CESSPOOLS P h y
VALIDATION ROBEFIT`A. WOOD
CK M O ASH SUPERVISING MECHANICAL ENGINEER
1 -
8 2.6 0-0 DEC23 1 0 D 7.00 CQ'