HomeMy Public PortalAbout6052 GOLDEN WEST AVE_Sewer__ 4/72
76A642L APPLICATION R -PERMI
76 A64
COUNTY OF LOS ANGELES SEWER—S W GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAR
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C
1
N 1
FOR APPLICANT TO FILL IN
LEGAL ►
DESCRIPTION LOT NO _ OWNER l...i i
I
5 MAIL
BLOCK TRACT/ �} ADDRESS
SIZE OF LOTS X 11 NOWONLOTEILOGS CITY TEL NO i
USE OF
DISTRICT NO GROUP MAP PR CESSED BY
BUILDINGS BK PG
N
TOR U j../ �--J 37
CONNECTION DATA
STATION DEPTH
TEL NO
LIC MANHOLE REFERENCE UPPER
NO CLASS Ls�G
DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
USE SEWER CONNECTING TO Y CURB PL ML TOPL
BLIC SEWER @ PCNOTIC TANK SEEPAGE PIT OR JOB NO O
S AND/OR DRAINFIELD @ CO IMP NOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO �n7 jVATE DISPOSAL SYSTEM @L `'NNEOT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
RK TO HOUSE SEWERERFLOW SEEPAGE PIT DRAINFIELD
N CESSPOOL DRYWELL MANHOLEER REPAIR OR ABANDON HOUSE HWY OR ST WIDENINGER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
OWNER'S PERMIT $
WASTE APPROVAL
CHARGES
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE FEE
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IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S R APPROVALS DATE INSPECTOR 5WNATURE
SIGNED THIS DAY OF 19 /p/► /a /y 01 1�
OWNER OR NEW HOUSE SEWER /�r'( 77 z lief
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SSEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR
ND/OR DRA DRAINFIELD
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 REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB/O'V'�F./QESCRI R A PRO R-L ABANDON HOUSE SEWER
SIGNATURE C.�C f BACKFILL SEPTIC TANKS ❑
OF PERMfTTEE L SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION
C�...O CASH
5 2 2 rZQC-1 1.4 1 0 9 1 5.0 0
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