HomeMy Public PortalAbout5934 GOLDEN WEST AVE_Sewer__ YO IN ERT
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COUNTY OF LOS ANGELES SEWE -SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B U 1 IR I N G
ADDRESS
J)OHN A. LAM IIE, County Engin�a�
WILLIAbI A. J£NSEN, Supt of BB 9 LOCALITY
(NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAILADDRESS _ .•
NO OF BLDGS. y
SIZE OF LOT NOW ON LOT 2- CITY . TEL. N0.+ /G
USE OF DISTRICT N0. GROUP MAP PROCESSED BY
BUILDINGS + �Q� ,
{/ BK PG "ay-,CONTRACTOR _ 7 '91
ADDRESS ee �9 l! CONNECTLON•DATA '
3 J STATION DEPTH
CITY TEL NO. _
ATE MANHOLE REFERENCE / -
REGISTRATION NO. ZS S� COUNTY L WER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
ITS AND/OR SEPTIC DRAEINFGIELDPIT
OR @ $3 00 Y. CURB .L." M,L:TO P,L.
OVERFLOW SEEPAGE PIT, DRAINFIELD r
EXTN CESSPOOL DRYWELL @ $2.00 -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 - -CO IMP N0. 130. 6illao'9. -
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENC
PERMIT NO
INDUSTRIAL
WASTE APPROVAL W
HA ES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE 1
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 4J1,GL.
L HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEfCTOA-SSIGkJhURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19-r NEW HOUSE SEWER !J`�0, QIVCY/�lLf
OWNER OR CONNECT ADDITIONAL ,
OWNERS AGENT - BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)' '
AND/OR DRAINFIELD
I HEREBY-ACKNOWLEDGE THAT I HAVE READ.THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO•COMPLY CESSPOOL ❑ DRYWELL ❑ -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS - ALTER,REPAIR,SEWER OR -SEWAGE DISPOSAL SYSTEM
-
1 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 OWNER OF THE ABOVE ABANDON HOUSE SEWER• - -
DESCRIBED RESIDENTI PROPERTY. BACKFILL SEPTIC TANKS ❑�
SIGNATURE - SEEP PIT(S9 ❑ CESSPOOLS -
OF PERMITTE �-
®' ATION ROBERT A. WOOD'
CK. N,0. CASH SUPERVISING MECHANICAL ENGINEER