HomeMy Public PortalAbout6058 GOLDEN WEST AVE_Sewer__ t S @IE•663 12-54
- FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
' Deportment of County Engineer
County of Los Angeles TADDRESS
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WM. J. FOX, COUNTY ENGINEER 5 Iva 04�� _ N L s/
CABSATT D. GRIFFIN, SUPT OF BUILDING ? 14 L � T�
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FOR,APPLICANT TO`FILL IN OSS ST. �`t-�'-ttY--/ /� ✓ -
LEGAL b�/. L aT�f� U
DESCRIPTION LOT NO!7 7 ,a OWNER +���
BLOCK TRACT Cp $' / ADDRESS
Al L
SIZE OF LOT LX NOWOONBLOTS �7-
7 CITY ! ���� £CJ L. NOA r (a7
USE OF
BUILDINGS-R_P S' /��/� P DISTRICT NO. GROUP MAP
�B K PG -
CONTRACTOR 6/0
ADDRESS - 41Z/vt L CONNECTION DATA �-
CITY �.-,A- TEL. NO.�O 11f7,,elwOV" STATION .1DEPTH h O
❑ STATE m MANHOLE REFERENCE
REGISTRATION NO � � � rj COUNTY t G{r UPPER I Lp .
-a' - TYPE OF CONNECTION LENGTH FROM �► GI
NO DESCRIPTION OF WORK FEES. CURB JL5! M L TO P L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100
I CONNECT ADDITIONAL BLDG. OR
WORK IMP. N0, JOB. NO.
_ CRK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT N0. 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
PERMIT CONNECTION CHARGE FEE
OWNER'S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
o
NTR
ITH THE
TRACTORHAVE T TOS CONNECTDATE O THEA ABODVEWDESCR BEDH EXISTING NAMED
DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLICt�S�EWER� j,
SIGNED THIS l� _DAY O�F7a///4�����- _19j>� NEW HOUSE SEWER , �� /__1
OWNER OR w�O„ - B AC ' Y!5� CONNECT ADDITIONAL
OWNERS AGENT[[[ Li(�t/N��C ///JJ/'' —�— BUILDING OR WORK
ADDRESS -� �`• -/�'>I� (�"►��==T SEPTIC TANK, SEEP, PIT(S) -
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL I--]AND 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
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL' OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. t BACKFILL SEPTIC TANKS❑ ,Q_,L
fTj,gi /I
-SEEP.'-PIT(S) C] CESSPOOLS (y �
SIGNATURE yy
OF PERMITTEE /
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
��o4 0 4 -'0.11 MAY-23 -4' ' 4.5 0
-BY _ _ i
DEPUTY DEPUTY „4 l
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