HomeMy Public PortalAbout5956 GOLDEN WEST AVE_Sewer__ 1
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6 E-683 3-SS �APPLiCAION TOR PERMI' _
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DIVISION OF BUILDING AND SAFETY SEWER-SE11 IGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINGfe
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST jf
CROSS ST. G (,
LEGAL +r_/
DESCRIPTION LOT N0. OWNER
BLOCK TRACT Y / MAIL
ADDRESS / f+
SIZE OF LOT-1700/or61 NO. OF BL
NOW ON LOT
CITY e � r TEL. NO
USE OF 5:4-
BUILDINGS
BUILDINGS o 12A`C DISTRICT NO. GROUPI MAP
5 BK PG
CONTRACTOR 1 E ` s
ADDRESS ,�il,j ,' CONNECTION DATA
A. f /
CITY TEL. NO , STATION ^ ! DEPTH �O
RI STATE MANHOLE REFERENCE �� C , �
REGISTRATION NO. ❑ COUNTY �•J
NO. DESCRIPTION OF WORK FEE
TYPE NECTIO
W N LENGTH FROM ^
HOUSE SEWER CONNECTING TO L Y CURB ) P L. M L TO P L 6� ♦�
PUBLIC SEWER Q $ 3 50 V
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. ORP
JOB N O
WORK TO HOUSE SEWER 1 00 CO IMP. NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 _ PERMIT NO
SEPTIC TANK, SEEPAGE PIT-OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNERS PERMIT CONNECTION CHARGE FEE
5 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEA ABOVE DESCR BEDCTED WITH THE HEREIEXIISNINGA NAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAy OF 9�� NEW HOUSE SEWER
e'o�MV �= �l lj� I �j •v CONNECT ADDITIONAL /
OWNER OR C7 F- "r` I✓'ICLr �1 1� f�G BUILDING OR WORK
OWNERS AGENT /
ADDRESS Sy, o lueh V/moi- / T"f SEPTIC TANK,SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I, HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL EIAND 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 I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COU Y AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OV R OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTI%PROPERTY, j
BACKFILL SEPTIC TANKS❑ ��
�~ -� SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE `
OF PERMITTE � - -
WILLIAM J. FOX,CO Y ENGINEER ALID$TION R.A.WOOD, CHIEF PLBG. INSPECTOR
�1 5 1 0 v APR 16 4 4.5 D in
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