HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Sewer__ &AE66312.54 _ APPLeI-CATION FOR �PE1�MIT
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DIVISION OF BUILDING AND SAFETY SEINER—SEWAGMISPOSAL
' Department of County Engineer
County of Los Angeles TN
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WM. J. FOX, COUNTY ENGINEER C��_�'jf,.i�CASSATT D. GRIFFIN. SUPT OF B�ILDING ,EARiST
FOR APPLICANT TO FILL IN .
LEGAL
DESCRIPTION LOT NO. CA' [��'G"Z-i" OWNER1-1
�. . a�.,y_i a
BLOCK TRACT s� ,G •'r' L-�Ir p5 A DRESS C - -^
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SIZE OF LOT '.�9,j y. OgG"-` NOW ONBLOTSCITY
'7>,, TEL. NO
USE OF
BUILDINGS DISTRICT
NO. GROUP / MAP
j , •' I I 4a K PG
CONTRACTOR '.
Jr �✓"` 7_7
ADDRESS r j � +��--,�--- f� _ CONNECTION DATA
CITY _i-r�:TEL. N0. )-^�„�;9 V'�� � STATION ` DEPTH
ry"/ � � ❑ STATE � �S MANREFERENCE
REGISTRATION N0. � ❑ COUNTY UPPER
TYPE OF'CONNECTION LENGTH FROM C� d
I No. DESCRIPTION OF WORK FEE CURB. ,eta M L TO P.L e7
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Qa $ 3 50
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR �f
�L WORK TO HOUSE SEWER 1 00CO. IMP NO. JOB. NO.
-
ALTER OR REPAIR EXISTING L� 0,>9 �te
--SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT N0.
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
CONNECTION CHARGE FEE
OWNER'S PERMT $ I 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECTDATE ONTRTHEA ABODVEWDESCR BED EXISTINGITH-THE HEREIN AMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER A�J
SIGNED THISDAY OF 95; 79 � NEW HOUSE SEWER SSS �OYX
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT I �f BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE/! ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. �/ BACKFILL SEPTIC TANKS El
TEl
J/ / SEEP. PIT(s) CE SPOOLS O yI0 I fit/! �lj/.aw,jf
SIGNATURE
OF PERM IT-TEE•/�V"
WILLIAM J/FOX, COUNTY ENGINEER VALIDATION
1�o EI' BY 9 8 AUG 4 4 5.5 0 In
BY ?
DEPUTY 1 DEPUTY
BY BY
-® DEPUTY DEPUTY