HomeMy Public PortalAbout6031 GOLDEN WEST AVE_Sewer__ 76A642C)
CE 808(REV 6,781 - APPLICA' ON'FOR MIT
os R" SEWER -,SEWAGE DISPOSAL
} COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN - DISTRICT NO -GROUP MAP,, i
,BK PG , PROC SSED BY 7 "
,
BUILDING //�`��
ADDRESS �J�
CONNECTION DATA
LOCALITY. � ,
NEAREST ( STATION ,DEPTH ,
CROSS ST
' UPPER
MANHOLE REFERENCE LOWER "
OWNER I, TYPE OF CONNECTION i LENGTH FROM
MAIL Y CURB. P L ML TOPIL
ADDRESS ..
PC NO
CO IMP NO ' JOB NO
CITY TEL NO
LEGAL + TRUNK PERMIT NO ROAD PERMIT NO '
DESCRIPTION LOTNO'
- AFFIDAVIT I WAIVER, EASEMENT RECORD INSTR NO DATE
BLOCK TRACT '
NO OF BLDGS +
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING ,
USE OF
BUILDINGS ' STATE ENCROACHMENT
PERMIT NO 1
` INDUSTRIAL
CONTRACTOR WASTE APPROVAL
ADDRESS
CHARGES
� �� ^
�•_f l CONNECTION CHARGE FEE
CITY L NO `
STATE1 / LIC REIMBURSEMENT FEE -
LICENSE NO G- CLASS
NO DESCRIPTION Off-WORK FEE APPROVALS D TE INSPECTOR' SIGNATURE
HOUSE CONNECTING TO
SEWER % O Q,j
I PUBLIC SEWER z '
NEW HOUSE SEWER
SEPTIC TANK SEEPAGE PIT OR I►►►1���---*
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK !lIMMM
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR SEPTIC TANK.SEEP„PIT(S)
WORK TO HOUSE'SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ '
EXTN CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR,ABANDON HOUSE ALTER,REPAIR,-SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND +
ABANDON HOUSE.SEWER
_ BACKFILL SEPTIC TANKS❑
OWNER'S''
Pe�mlt S SEEP PIT(S)❑ CESSPOOLS❑
`
AUTHORIZATION TOTAL FEEVALIDATION
O
I HAVE AT,;THIS,DATE A.CONTRACT WITH THE HEREIN NAMED CON- �i- .I� _-.
TRACTOR TO CONNECT THE'ABOVE DESCRIBED EXISTING DWELLING ••G #'"C) O O;O 1 O +
TO THE PUBLIC SEWER ���
SIGNEDTHIS - DAY OF - 19_ ///CCAA.• 2'0 0 A 0 0
OWNER OR' ,
OWNERS AGENT "
0001ao"o5
ADDRESS
t
-IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ` _ �.�0'2.,,8 ^
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY v
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
S
LICENSED AREQUIRED BY LOS ANGELES COUNTY AND STATE OF
LII
CAFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDEIAL PROPERTY 1
SIGNATUREOF PERMITTEE