HomeMy Public PortalAbout5950 GOLDEN WEST AVE_Sewer__ 5&E-689 11.85
6D
S APPLICATION ICOR PERMIT 1
&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS d (J
® - CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL [y n OWNER
DESCRIPTION LOT NO CS aGI
6 S61 MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS CITY TEL. NO.
SIZE OF LOT -NOW ON LOT
USE OF _ DISTRICT N0. I GROUP MAP
BUILDINGS -
BK PG ,
CONTRACTOR
ADDRESS - CONNECTION DATA
s` STATION DEPTH
CITY TEL. NO. T MANHOLE REFERENCE _ UPPER
❑ STATE LOWER
REGISTRATION N0. ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION. LE TH FROM
PUBLIC SEWER @ $3 50 Y. CURB P TO P.L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD. @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD - PNO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO !OB 0.
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT-NO. ' ROAD PERMIT NO.
CONNECTADDITIONALBLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE h INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 !/O WASTE APPROVAL i
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWEER/} NEW HOUSE SEWER
SIGNED THIS =DAY OF��� elide 19> CONNECT ADDITIONAL
OOWNER ORWNERS AGENT _ r Of . BUILDING WORK
^- SEPTIC TANK
,SEEP, PITS)
ADDRESS &- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE R AD THIS APPLI TION CESSPOOL❑ DRYW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO MPLY
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 DISCONNECT PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF D
ABANDON HOUSE SEW
CALIFORNIA OR THAT I AM THE LEG L OWNER OF THE ABOVE
ER
DESCRIBED RESIDENTIAL PRO RTY � BACKFILL SEPTIC TANKS❑
SIGNATURE _
SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE. COUN Y ENGINEER VALIDF�� IO OBERT A WOOD, CHIEF PLBG INSPECTOR
CK. M 0. CASH
1 04 S:7-' NOV'21 4 2.:00 Q