HomeMy Public PortalAbout6204 GOLDEN WEST AVE_Sewer__ I, 1q� _®pg�� •
s&E-6D A■ ■ LI-C TIO . 170■ \- ■ ERMIT 7
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depm'tment of County Engineer
County of Los Angeles BUILDING �y
WM. J. FOX, COUNTY ENGINEER ADDRESS y _ gyp'
{ •CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY-
FOR APPLICANT TO FILL IN NEAREST
11 CROSS ST.
LEGAL �/
DESCRIPTION ,.- LOT N0. �`ry�-Y \ � �r .ayM.v� OWNER
T
BLOCK TRACT MAIL d
N0. OF BLDGADDRESS
S. _
SIZE OF LOT rQ NOW ON LOT CITY TEL. N0.
USE OF [[[����)n �e � Romeo= N
BUILDINGS ,�� �, DISTRICT NO. GROUP MAP
CONTRACTOR B K PG�
ADDRESS- '^ a.� Q� A CONNECTION DATA
CITY _ a. nr,, TEL. NO. ^Jr STATION 7 G r '_ DEPTH
® / ❑� '� MANHOLE REFERENCE �- f_
REGISTRATION NO t t„ G�'.� �i(-❑ COUNTY UPPER / 7.�f T�.uWER�
�99auea� TYPE OF-CONNECTION - LENGTH FROM — _2�
NO. DESCRIPTION OF WORK FEE_ - Y CURB ", P L. M L.TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER - Q S•3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL. 1-06 BLDG. OR
WORK TO HOUSE SEWER ---. -- - 'CO.-IMP.-NO, -/ --" JOB.-NO:
ALTER OR REPAIR EXISTING - J
_ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO.' �r'
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT f
_ 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
PERMIT CONNECTION CHARGE FEE
OWNER'S s I Oo
AUTHORIZATION ,TOTAL FEE �� REIMBURSEMENT FEE,,"
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS J ^DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF n ig � NEW HOUSE SEWER
OWNER OR �^� � r CONNECT ADDITIONAL
OWNERS AGENT r BUILDING OR WORK
' SEPTIC TANK, SEEP, PIT($) -
ADDRESS AND/OR DRAINFIELD
7 _ -
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 ANDSEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY 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❑
SEEP. PIT(S) [:]- CESSPOOLS (] S
SIGNATURE �'�\}
OF PERMITTEE -
r
WILLIAM J. FOX, CO T Y\ N AI t TION•
BY _AJC,07B:5'0 2 S, AUG 3J0 4 4.5 0 m
DEPUTY DEPUTY
BY BY
,'® DEPUTY DEPUTY