HomeMy Public PortalAbout6126 GOLDEN WEST AVE_Sewer__ 76A•'642D.--CE808 - 9/73 APPLICA N FOR1" MIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 7
ADDRESS `(Z, r
LOCALITY
NEAREST
FADDRESS
OR APPLICANT TO FILL IN CROSS ST.
L _1
TION LOT NO. OWNER (``
f MAIL
TRACT) ��'/ ADDRESS r- .j ,/ y y
LOT�� /2'J NOW OON LOTS CITY -. EL. NO. yLiz y C' Gr/
GS DISTRICT NO. GROUP MAP ESSED BY
BK PS
TOR V A� (I) f '�'. (rte/ ,�� 1-- 77
O j • , j� `L � C�IONNECTI N DATA
STAT �''7��( TEL. NO. ���' ASTATION 34�l.F ,,5 DEPTH
NO:_ ` dV CLASS MANHOLE R••E//FERENVC Ev� � a��.�,� [ LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OFC ON
LENGTH FROM 1
HOUSE SEWER CONNECTING TO Y. CUR P.L. M.L.TO P.L. a
PUBLIC SEWER $7.00
SEPTIC TANK.SEEPAGE PIT ORP.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.9/3JLS
PRIVATE DISPOSAL SYSTEM @ $3.00 ///"""
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 d
OVERFLOW SEEPAGE PIT.DRAINFIELD V
EXTN..CESSPOOL.DRYWELL. Q $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT F�
MANHOLEQ $7 00 PERMIT NO. W
INDUSTRIAL D N
WASTE APPROVAL Q
HARGES
OWNERS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE J
1 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 ` Afi.° ,
r.
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
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL [:1
ID
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL FCRNIA OR THAT I AM E LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE C ]BED RESIDENNTIAL./JPROPE'RTY. ABANDON HOUSE SEWER
SIGNATURE L, k4a BACKFILL SEPTIC TANKS Cl
PER MTfTEE -P SEEP. IT S)
❑ CESSPOOLS ❑
VALIDATION M.0. CASH
4 7 $'nOCT 1 1 J 1) 1 5.0Q ALlo
G