HomeMy Public PortalAbout6212 GOLDEN WEST AVE_Sewer__ 24650 INSE S
76606 6-80 APPLICATION" .FOR PERMIT . .
78A642U COUNTY OF LOS ANGELES SE,WEFt, ,SgWAGE -DISPOSAL,, ,,.
DEPARTMENT OF COUNTY-ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
II
JOHN A. LAMBIE, County Engineer -�--
WILLIAM A. JENSEN, Sup't of Building LOCALITY T `
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. OWNER;
BLOCKMAIL
TRACT. - ,
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY .. TEL NO
BUELDINGS J DISTRICT NO. GROUP MAP - PROCESSED BY Y•
DUSOF
BK PG
CONTRACTOR
ADDRESS -�/ - CONNEC ON DATA
CITY TEL NO. O TATION Q DEPTH -
a
STATE
REGISTRATION NO - 1y COUNTY 'MANHOLE REFERENCE
(/ LOWER
NO DESCRIPTION OF'WORK E - ,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 I TYPE OF XafjAgCTION LENGTH FROM
SEPTIC,TANK SEEPAGE PIT OR - Y. CURD P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00 _ -
OVERFLOW SEEPAGE PIT, DRAINFIELD -
EXTN' CESSPOOL DRYWELL @ $2 00 -
P.C.NO. -
HOUSE SEWER CONNECTING TO 'COIMP N0. - JOB NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 � "
CONNECT ADDITIONAL BLDG.OR , TRUNK PERMIT N0. ROAD PERMIT'N0. ��, Q
WORK TO HOUSE SEWER @ $1 00 V
SEWER OR DISPOR ABANDON OSAL SYSTEM HOUSE @ $1 OO STATE ENCROACHMENT Py
PERMIT NO O
INDUSTRIAL - F
-'WASTEAPPROVAL W
CHARGES W
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION' TOTAL FEE REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE ESC IBED EXIISTDATE A CONTRACT WITH THE I1NGgMED DWELLING APPROVALS •DA'Z'E INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED-THIS DAY OF/ 9= NEW HOUSE SEWER
OWNER OR .. /1 '� CONNECT ADDITIONAL
OWNERS AGENT / ' C BUILDING OR WORK - -
SEPTIC TANK,SEEP PIT(S) '
ADDRESS AND/OR DRAINFIELD `
I 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 WS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE,DISPOSAL SYSTEM w
I HEREBY CERTIFY THAT AM PROPERL REGISTERED AND/OR DISCONNECT PLUG AND, -
LICENSED AS REQUIRED BY LOS GELES OUNTY. AND.STATE,OF ABANDON HOUSE SEWER '
CALIFORNIA OR THA 1 M LEG OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDE AL R;. r SEEP. PLLSE ❑-CESSPOOLS_
SIGNATURE - '
OF PERMITTEE ,
OF VALIDATIO ROBERT A. WOOD'
^ CK, X.o, CASH SUPERVISING MECHANICAL"ENGINEER_
��. 7 a 2:� AUG 21. 1 1. G� �5 .0 C I.