HomeMy Public PortalAbout6043 GOLDEN WEST AVE_Sewer__ DEP" MENT OF COUNTY ENGINEER - 'SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS �� l
" FR'OAPPLICANT TO FILL IN l LOCALITBUILDING NEAREST
Y}'��- - 11`t j
ADDRESS g�'LIl eu. Aye, CROSS ST. Q a
LOCALITY L f,T- aM ja�e',p DISTRICT NO. SERIAL NO. PERMIT N0.
NEAREST -V' Y`` ��y
CROSS ST., W-rind-mif-F, Aye -'s A ��icl Co-� S
• RECEIVED BY Ready for Inspection DATE ISSUED,
OWNER r Yr Eml ab al, -)-—\ m-64
MAILUSE E OCCUPANCY MAP
ADDRESS Same
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CITY Ti n-b a TEL-NO. Am o n. 2� _\ � C 1 3
CONTRACTOR (ligaMe ftof enbfmg CO.IMP.NO. - �® - C'� � �•r
ADDRESS �3�g , 'Q��n�»@st A�j JOB NO.
CITY �' TEL.NO. t TRUNK PERMIT NO.
ATE
REGISTRATION NO. OAD PERMIT NO.LEGAL
DESCRIPTION L T N r/""407 F7 STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT � � ' WASTE APPROVAL
SIZE CF LOT SU N/;L N0.OF BLDG8.
NOW Oq LOT '�_ CHARGES
USE OF
BUILDINGS- Dwel71 i ntr Ot Qgr@80 - CONNECTIO ARGE FEE
NO. DESCRIPTION Or WORK FEE
CONNECTING TO
REIMBURSEMENT FE
HOUSE SEWER _
PUBLICSEWER a $ 3.50 RECEIPT NO. TE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO- I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION .� }�-'� DEPTH
CESSPOOL—DRYWELL ^
SPECIAL CONDITIONS ONLY 2.00 I
SMAN EFERENCE
• •\OZ�G CS
TYPECURB- CTION LENGTH FROM
OWNERS PERMIT $ 1 00 ' M.L.TO P L.
AUTHORIZATION I TOTAL FEE
r
I HAVE THIS DATE CONTRACTED WITH THE'HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'3SIGNATURE DATE
. 1
SIGNED THIS....-..............DAY OF------------- NEW HOUSE SEWER -
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT—..... r� ...��... BUILDING OR WORK
---------------..--..-.---------._ SEPTIC TANK,SEEP.PIT(S)
ADDRESS----
_-------------------•---.._..-----.. AND/OR ANKS EP.
ELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS 'ALTER,REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ,DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 THE LEGAL OWN- 'ABANDON HOUSE SEWER
ER-OF THE ABOVE D CRIBED'RES OE IAL PROPERTY. ,BACKFILL SEPTIC TANKS E
SIGNATURSEEP.PIT(S)❑ CESSP00LS _� Y6� ¢r a"4
E
OF PERMITT
76A642D 663 1/53 ,�/'