HomeMy Public PortalAbout6134 GOLDEN WEST AVE_Sewer__ &EE•-88669 11-DS
SAPPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County. of Los Angeles BUILDING %
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITYNEAREST
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FOR APPLICANT TO FILL IN CROSS ST -
LEGAL 5 ` 0 i%6 C OWNER
DESCRIPTION LOT NO.
MAIL a
BLOCK TRACT 54,tf$ t ADDRESS -
NO. OF BLDGS. J ~CITY TEL N0.
SIZE OF LOT NOW ON LOT / ,
USE OF DISY-11BK
0. GROUP MAP
BUILDINGS PG
CONTRACTOR - 6♦�-r
ADDRESS CONNECTION DATA
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STATION;� ♦ EPTH
CITY �ri( TEL. NO
MANHOLE REFERENCE 7
y Q—&FATE Hyl LOW
REGISTRATION NO �` ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF ONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y_ M L.TO P.L.
PUBLIC SEWER @ $3 50 (�
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELDP. C. NO. -
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO. IMP N0. � � JOB NO.
HOUSE SEWER CONNECTING TO FV f
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO. ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO.
•ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00-
REIMBURSEMENT FEE / ft•� d 101-b a1pp
AUTHORIZATION TOTAL FEE d ni tMt
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THISDAY OF 19 CONNECT ADDITIONAL
OWNER OR w� BUILDING OR WORK '
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS PPLI CATION 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW DISCONNECT PLUG AND
D
CALIFORNIA OR THAT I A THE LEG OWNER OF THE ABOVE
ER
DESCRIBED RESIDENTIAL P PERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE.VpNTY ENGINEER VALIDATION ROBERT A WOOD. CHIEF PLBG INSPECTOR
CK N O CASH ry
Q 4 6, o JAN 3 4 A . 4.5 0 �