HomeMy Public PortalAbout6049 GOLDEN WEST AVE_Sewer__ 76A 6420 - �E608 - 9/73 APPLICA ION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL-
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS ` TBY
LOCALITYNEARESTFOR APPLICANT TO FILL IN CROSS STLEGAL
DESCRIPTION LOT NO OWNERMAIL
BLOCK TRACT ADDRESS'
NOOF SLOGS SIZE OF LOT NOW ON LOT CITY Z TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSBUILDINGSBK p3
FONTRA O
ADDRE `� a CONNECTION DATA
n� STATION DEPTH
STATE J� LIC MANHOLE REFERENCE UPPER
LOWER
LICENSE NO • .f9 GLASS
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L MIL TOP L
PUBLIC SEWER $7.00
P C NO
SE TIC TANK SEEPAGE PIT OR
S AND/OR DRAINFIELD Q fl0 00 CO IMP NO JOB NO
SE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
P _ATE DISPOSAL SYSTEM S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlv[I [A19M[M7 RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® $300 cy '0 _ <L
OVERFLOW SEEPAGE PIT DRAINFIELD C.1
EXT N CESSPOOL DRYWELL @ SS 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING � I=SEWER OR DISPOSAL SYSTEM $300 _ STATE ENCROACHMENT C l
MANHOLE $7 00 PERMIT NO W
INDUSTRIAL / N
����+. i WASTE APPROVAL Z
O`�_�VNERIJ IT PERMCHARGES
v CONNECTION CHARGE FEE -
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS - DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT - - ---
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD w
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH'ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ '
I HEREBY CERTIFY THAT I AM PROPERLY REGIS T RED AND/OR ALTER.REPAIR SEWER OR -
LICENSED A REQUIRED BY LOS ANGLES COUNTY NO STATE OF SEWAGE DISPOSAL SYSTEM - -
CALIFC,RNI/r R THAT 1 AM THE LEGAL OWNER OF NO INTEND TO DISCONNECT PLUG AND
RESIDE IN HE AS E DESCRIBE RES IDEN AL ROPER Y ABANDON HOUSE SEWER
SIGNATU BACKFILL SEPTIC TANKS ElOF PER
[].-CESSPOOL
VALIDATION CK. M. CASH
9 9 O-OEC 251 ,1 t� D .5 Q
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