HomeMy Public PortalAbout5938, 5938 1/2, 5940, 5940 1/2 GOLDEN WEST AVE_Sewer__ S&E-6D - APPLICATION' FOR PERMIT
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8$E-88DIVISION'OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING �� ��� �A'Vi."
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JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 1 (,(f
® CASSATT D GRIFFIN, SUPT OF BuitDlNo LOCALITY
4
FOR APPLICANT TO FILL IN CROSS ST.
LEGALgo OWNER
DESCRIPTION LOT NOAd
% MAIL
BLOCK TRACT - ADDRESS g
i
NO. OF BLDGS CITY TEL NO.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO'. GROUP - MAP
BUILDINGS, _ BK PG
T.
CONTRACTOR C� s .,
ADDRESS •CONNECTION DATA'
��
STATION DEPTH
CITY TEL. N0. r MANHOLE REFERENCE PER
[�S` ATE
REGISTRATI NO Z ,f/ ❑ COUNTY
NO. DESCRIPTION OF WORK 'FEE TYPE OF RB CTI ON
LENGTH FROM
HOUSE SEWER CONNECTING TO Y, •CU ,P.L M.L TOP L. .26
PUBLIC SEWER @ $3 50 -
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD - @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD _ P. C NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 (/ cis TRUNK PERMIT NO. ROAD PERMIT NO./(Dr-
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER - Q $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE PNDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL` - -
CHARGES
CONNECTION,CHARGE FEE
OWNER'S PERMIT $ 1 00
-
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I 'HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECL-TH-E ABOVE DESCRIBED EXISTING DWELLING / I /,�
TO THE PUBLIC SEWE NEW HOUSE SEWER !/�
SIGNED THIS DA OF 19 CONNECT ADDITIONAL
OWNER OR - BUILDING OR WORK
OWNERS AGENTIV, SEPTIC TANK,SEEP,PIT(S)
ADDRESS- AND/OR DRAINFIELD - -
IH
EREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ i
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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA 0 THAT I M THE-LEGAL OOWNROF T E BOVE DE lB RE N OPE BACKFILL SEPTIC TANKS SEEP PIT(S),❑ CESSPOOLS
OF PERMITTEE rl
JOHN A LAMBIE, COUNTY ENGINEER VALIDATIObL_ ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK M OCASH
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