HomeMy Public PortalAbout6059 GOLDEN WEST AVE_Sewer__ 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT _
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS tea' /�1�1'�B.t�!•rJ.ES
LOCA L ITY� '7
FOR APPLICANT TO FILL IN �ROSSg5T V_16100/11,4wllLEGAL C
DESCRIPTION LOT NO U OWNER /� ♦ b/�a.��/Y�.CLIK
_ MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS _
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF
BUILDINGS DISTRICT NO GROUP BK p5 MAP PROCE ED BY
T
CONTRACTOR Q 3
ADDRESS CONNECTION DATA
CITY TEL NO STATION f �•- DEPTH
STATE LICMANHOLE R J / UPPER
LICENSE NO. CLASS ENCE •j (� r OWE
NO DESCRIPTION OF WORK FEE TYPE OF TION (J - LENGTH FROM f
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER a $7.00
C NO
SEPTIC TANK SEEPAGE PIT O-R
J
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO J
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I NAIV[I•I IAl ININY RECORD INSTR NO DATE
WORK TO HOUSE SEWER $300 Cr..
OVERFLOW SEEPAGE PIT DRAINFIELDCOG
EXTN CESSPOOL DRYWELL $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING I=
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT �
MANHOLE $7 00 PERMIT NO W
INDUSTRIAL 0-
WASTE APPROVAL N
Z
OWNERS PERMIT s o CHARGES —
'
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE 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
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYW ELL' ❑ -'
I HEREBY CERTIFY
TH T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS•�REQUIRE BY.LOS-_A10CES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCi I, OR THAI AM TH E'L EGAL OWNER OF AND INTEND TO
R]SE .� AB ES RIB D DENTIAL PROPERTY DISCONNECT PLUG AND
ABANDON HOUSE SEWER
E E BACKFILL SEPTIC NKS ElSEEP PIT IS) OOLq m'
VALIDATION M.0. sH
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