HomeMy Public PortalAbout6210 GOLDEN WEST AVE_Sewer__ '24650,INSERTS
'•7GA642D W - APPLICATION. FOR PERMIT, -
', 78A842D - '
COUNTY OF LOS ANGELES SEWER- ,SEWAGE DISPOSAL, �*
DEPARTMENT OF COUNTY'ENGINEER '
BUILDING L.AND SAFETY DIVISION ''BUILDING-
q ADDRESS
WILLIAM AJENSENCSup tt ofnBuildiaq LOCALITY
P:, r
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.- ` J
LEGAL _ 'OWNER
DESCRIPTION LOT N0. - '
BLOCK TRACT MAIL '
ADDRESS -
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY - TEL NO
USE DISTRICT N0. GROUP MAP PR CESSED BY
BUILDINGS 1 I7' BK PG I
CONTRACTOR - „� 51 `d l
ADDRESS """YYYIIIIII��������� CONNECTION DATA
CITY TEL NO. STATI 0 DEPTH
�� e STATE MANHOLE REFERENCE
REGISTRATION NO Y COUNTY LOWER
NO DESCRIPTION'OF WORK FE
HOUSE SEWER CONNECTING TO
_ ....JJ1 '
PUBLiC SEWER @ $3 00 v V TYPE OF CONN C LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR 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 JOB NO,
CONNECT ADDITIONAL BLDG OR -
WORK TO HOUSE SEWER TRUNK PERMIT NO. ROAD PERMIT NO.,' p
@ $1 00' V
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT 07
PERMIT NO 0
INDUSTRIAL
WASTE APPROVAL W
_ CHARGES taA
*•OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT'TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH'THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. / �y
SIGNED THIS DAY OF 19 NEW HOUSE SEWER 6 �h
OWNER OR CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK -
ADDRESS' SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 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
PLUMBING AND SEWERS. ALTER,REPAIR SEWER OR
HEREB
1 Y CERTIFY T SEWAGE DISPOSAL SYSTEM
T 1 AM PROPERLY EGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIR BY ANGELES LINTY AND STATE OF_ ABANDON HOUSE'SEWER
CALIFORNIA OR I E LE A WNER OF THE ABOVE
DESCRIBED 0 Y. ��' SEEP.F
Cl
SIGNATURE PIT(S) ❑ CE ILL SEPTIC TANKS SPO L [:I-
OF
-" -
OF PERMITT ..
®" VALIDATION-------) ROB A. WOOD
cK- X.0. —H SUPERVISING MECHANIC-AL
HANICAL ENGINEER
LAf c 1 7 3 0 - 0b ? ACD 5 .0, -
2465011NSERT
-769090 APPLICATION FOR PERMIT , y
^ZeAgazo COUNTY OF LOS ANGELES SEWER-SEWAGE .PISPPSAL-
_ DEPARTMENT OF COUNTY ENGINEER'
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 6
JOHN A. LAMBIE, County Engineer T
` WILLIAM A. JENSEN, Supt of Building LOCALITY '
NEAREST.
LEGAL'
'FOR APPLICANT TO FILL IN clloss sr.
. � � r -� :•
/�'
DESCRIPTION` 'LOT NO. OWNER - '
BLOCK TRACTMAIL
:ADDRESS,
NO OF RUGS. -
SIZE OF LOT NOW,ON LOT .CITY TEL NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS I BK PG I
CONTRACTOR J -�
ADDRESS , CONNECTION DATA
CITY TEL N0. AT N DEPTH !�
STATE MANHOLE REFERENCE
REGISTRATION NO / ® COUNTY i LOWER
No DESCRIPTION OF ORK FEE _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CON LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00 r
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO.' ROAD PERMIT NO./<j/,7
WORK TO HOUSE SEWER @ $1 00 U
SEWER OR DIIR OR
ABANDON
H @ $1 00 STATE ENCROACHMENT as
PERMIT NO 0
f — INDUSTRIAL
WASTE APPROVALP.
_ W
CHARGES rrn
OWNER'S PERNIIT $ ,y- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE V REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE HEEINAMED CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE .INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. +
SIGNED THIS DAY 0 19_ NEW HOUSE SEWER P v -lm, X'l.,"/L fist
OWNER OR CONNECT ADDITIONAL '
OWNERS AGENTS BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS) -
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - , • � -
AND STATE THAT THE ABOVE, IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL'COUNTY 0 INANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEW SEWAGE DISPOSAL SYSTEM
1 HEREBY C FY THAT 1 AM PROPERLY REGIST RED AND/OR DISCONNECT PLUG AND
LICENSED AS QU ED BY LOS ANGELES COUNTY ND,STATE OF ABANDON CT PLUGHOUSE AND '
CALIFORNIA R AT 'I AM THE LEG OWNE .OF THE ABOVE
DESCRIBE ES TIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ ,
SIGNATU E
SEEP.PIT(S) ❑ CESSPOOLS ❑ _ -
-
®" VALIDAT[ ROBERT A: WOO
M.o. CASH SUPER ISING MECHANICAL ENGINEER '
( �
'7 3 1 AUG 1 D � 5.(� 0 M
_ _ 0