HomeMy Public PortalAbout6206 GOLDEN WEST AVE_Sewer__ 24650;INSERTS "
,.CE802APPLICA`T'I®N� FOR PERMIT
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COUNTY OF 10S ANGELES SEWER-SEVi/ACE. D SP®SAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDINBUMDING AND SAFETY DIVISION 7,NEAREST
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JOHN A. LAMBIE, County Enmser
WILLIAM A. JENSEN. Supt of Building +
FOR APPLICANT TO FILL IN
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LEGAL, OWNER „J N`•_
-DESCRIPTION' LOT N0. - ''
BLOCK TRACT 'MAIL - - - -
ADDRESS
NO OF BLDGS. -
SIZE OF LOT NOW ON LOT CITY TEL N0:
USE OF, DISTRICT NO.] GROUP MAP P SED BY
BUILDING I
CONTRACTOR' �O LrBK PG, J
ZEE
,ADDRESS CONNECTION DATA
CITY TEL.NO. 71 ,ST TIONj DEPTH
TATE 'MANHOLE REFERENCE
REGISTRATION 140. COUNTY i LOWER"
NO. DESCRIPTION OFrWORK EE ;
HOUSE SEWER CONNECTING TO $
'PUBLIC SEWER • @ $3 00 ✓ TYPE OF CONN T LENGTH FROM - 1
SEPTIC TANK,SEEPAGE PIT OR L. M.L.TO P.L. _
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD -
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP N0. ZZJ JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1 00 ,TRUNK PERMIT NO ROAD PERMIT N0. zi
Q
- _ - V
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO ca
p
INDUSTRIAL
WASTE APPROVAL W
CHARGES Vim!
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE rl
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE NAMED CON-
TRACTORATO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT THE ItNG DWELLING APPROVALS DATE INS CTOR'SSIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR /� CONNECT ADDITIONAL
OWNERS AGENT '(e '.6„ BUILDING OR-WORK - -
ADDRESS SEPTIC TANK,SEEP.PIT(S) •
AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - • - - •-•
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING_ ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY T AT I AM PROP LY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQKApr,
BY LOS ANGE S COUNTY AND STATE OF ABANDON HOUSE SEWER '
CALIFORNIA OR THE L AL OWNER• OF THE ABOVEDESCRIBED-RESRTY., BACKFILL SEPTIC TANKS ❑SIGNATURE i'
SEEP PIT(S) ❑ CESSPOOLS ❑ - F
OF PERMIT41-17 JLJ�T
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®P =VALIDATIO ROBERT,A. WOO
} -, cK ,a.o; GSR SUPERVISING MECHANICAL ENGINEER fia;;
24650 INSERTS
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7APPLICATION FOR PERMIT'' .
' aneasn COUNTY OF LOS.ANGMXS SEWER,-SEWAGE9DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
AND SAFETY DIVISION BUILDING / 2-p6
ADDRESS (L7
JOHN A. LAMBIE, County Engineer
i WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST r`
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER xf
DESCRIPTION LOT NO. _
BLOCK, TRACT MAIL
'ADDRESS - _
NO SOF BLDGS. -
SIZE OF LOT - NOW ON LOT CITY -TEL.NO.
USE OF
` / DISTRICT NO. GROUP MAP S 6
BUILDINGS PROCSED BY
IBK PG
CONTRACTOR
ADDRESS • va CONNECTION DATA v -
CITY �-- TEL N0. 47 0 ST ION DEPTH '
STATE MANHOLE REFERENCE
REGISTRATION N0. Gp V (, COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO '
PUBLIC SEWER @ $3 00 TYPE OF CONNE T LENGTH FROM- -
SEPTIC TANK,SEEPAGE PIT OR P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL-DRYWELL @ $2 00 '
HOUSE SEWER CONNECTING TO P.C.'NO. '
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO. '32JOB NO. „
` CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO. Q
WORK TO HOUSE SEWER @ $1 00 U ,
SEWER OR PAIROSR ABSA HOUSE @ $1 00 STATE ENCROACHMENT _
PERMIT NO. p
—� ,INDUSTRIAL U
WASTE APPROVAL •W
CHARGES vAi
OWNER'$ -PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
NAMED CON-
TRACTOR TO CIONNECT T EDATE AO ABOVE DESCRIBED EEREISTWITH THE ItNG DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. { l /'J
SIGNED THIS DAY O� 19_ NEW HOUSE SEWER �/ N
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
.ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ'THISAPPLICATION - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL _
WITH ALL 'COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIF THAT ^I /AMPPERLY REGISTERED .AND/ORDISCONNECT PLUG AND
LICENSED AS 0 ED LOLES COUNTY ANDSTATE OF BANDON HOUSE SEWERCALIFORNIA IRT 1AL OWNER OF THE ABOVE
DESCRIBED P SEEP BACKFPIT(S) CESSPOILL SEPTIC TANKS'OLS
❑
SIGNATOR
OF PER TTE
OF VALIDATIO RO ERT A. WOOD
CIL M.o. CASH SUPERVISING MECHANICAL ENGINE
F_R -
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