HomeMy Public PortalAbout6138 GOLDEN WEST AVE_Sewer__ 642D 6 o8 2/70
76,A APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER IA
BUILDING AND SAFETY DIVISION FADDRESS
Uu'
JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUPT. OF BUILDING e' p? j If fOR APPLICANT TO FILL IN ��
(PRINT OR TYPE ONLY)
LEGAL \
DESCRIPTION LOT NO. OWNER .� �,j`�`-"'��
MAIL
BLOCK TRACT ADDRESS/• O
NO. OF SLOGS. j
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP I CLASS I MAP PROCESSED BY
BK /pG
CONTRACTOR
ADDRESS �'+ CON NEQQCCTIONhC�Dl4A'. S6
L jj� jl STATION DEPTH
CITY TEL. NO. ..�"
STATE LIC UPPER
LICENSE NO; CLASS ` MANHOLE REFERE CE LOW R
NO. I DESCRIPTION OF WORK FEE TYPE OF CONN TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CUR P.L. M.L.TO P.L.
PUBLIC SEWER 55.00 '
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD C $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. D PERMIT
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR gFFIDAVIT WAIVER EASEMENT RECORD.IN NO. DATE U
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALAOR ABANDON HOUSE HWY.OR ST.WIDENING 0
S R.DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT U
PERMIT NO.
INDUSTRIAL h
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT $1 21 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE 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
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM '
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
DISCONNECT PLUG AND
RESIDE IN, THEA DES gIBED ggqESIDENT ^t�PROPERTY.
E ` �j /±+ 1 ABANDON HOUSE SEWER ot
SIGNATURE 1 /LJr/ ?//// BACKFILL SEPTIC TANKS ❑ /�
OF PERMTTT, E _ SEEP.PIT(S) ❑ CESSPOOLS ❑¢'/' 1Le
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
E ,fir_ J 3 3� JUl27 1 05.t00
CE908 12-68
76A 642D APPLICATION, RM FOR �I®e.t�
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BUILDING Golden West
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY Temple City
NEAREST Flaherty St®
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL
DESCRIPTION LOT NO. ,y��J OWNER Richard Bowen
BLOCK TRACT fin' ao'r MAIL 1.620 Melanie Ln.
ADDRESS
NO. OF BLDGS. 1 CITY Arcadia TEL. NO.
512E OF LOT NOW ON LOT
USE OF
BUILDINGS Res. DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR S uare Deal Sewer SerV is 5-0 /— `7BK -7
ADDRESS 2933 Maxson Ado CONNECTION DATA -n-
CITY El Monte TEL. NO. 444-2020 STATION 15Z•��� DEPPTT.H 15i J
LICENSE NO: 128870 CLA':TATE LIC 55 C-42 MANHOLE REFERENCE �/ "� ..� L.` UPPER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION �'�L-ECN`GG�T�H FROM
1 HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD SIO.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO �j
PRIVATE DISPOSAL SYSTEM @ S3.00 TRUNK PERMIT NO. ROAD PERMIT NO.� YCL
(J
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEXEXT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER 0 $3.00
O.
OVERFLOW SEEPAGE PIT,DRAINFIELD C:)
"XT N..CE55POOL,ORYWELL,MANHOLE 0 $5.00 I (—
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING V
SEWER OR DISPOSAL SYSTEM @ S3.00
STATE ENCROACHMENT CL�
' PERMIT NO. CIO�
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT sl 2 00
AUTHORIZATION TOTAL FEE 70 CONNECTION CHARGE FEE
1HAVE AT THIS DATE A .CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE c
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER- DATE IN CTOR'S SIGNATURE
SIGNED THIS DAY OF 19IF!
OWNER OR NEW HOUSE SEWER / �j✓
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT,I HAVE READ THIS APPLICATION A:NDJOR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY A D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, A D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO E DEIBED RESIDENTIAL P PERTY ABANDON HOUSE SEWER
SIGNATURE S BACKFILL SEPTIC TANKS [IOF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
GK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER
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