HomeMy Public PortalAbout6213 GOLDEN WEST AVE_Sewer__ S&E•889 11.93 APPLICAT�ON FOR PERMIT
DIVISION OF BUILDING AND SAFETY S Edi!E P-SEWAGE D 9 S POSA L
Deparbnent of County Engineer N
County of Los Angeles BUILDING
Poo
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT of BUILDING LOCALITY ( c7 '
F04 APPLICANT TO, L IN CROSS S
LEGALr r
DESCRIPTION/ CYST N0. X v - OWNER
-(�'' /� MAIL
BLOCK TRACT /,/'
�O_n Q. an,.yam
' 1 Q �_4n(_.00S ADDRESS /'�r0 (� )/Ao )es
N0. OF BLDGS�� CITY yF fi 0. 7�O(G
SIZE OF LOT NOW ON LOT nom, re
USE OF (7 �• �`�'
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR41Z r yA _
ADDRESS �3 VA CONNECTION DATA
7 R_ ?9., amt
STATION112-)01-3 DEPTH
CITY STEL. NO. ��pppj MANHOLE REFERENCE
�. /////sss ❑ STATE - { •" ,� LOWER
REGISTRATION NO. �r d / ❑ COUNTY • ''�,,.
NO. DESCRIPTION OF WORK FEE FA TYPE OF CTION LENGTH FROM
HOUSE
PUBS C SEWSEWER CONNECTING TO @ $3 50 Y. C R ) P L. M.L.TO P.L.
b
SEPTIC TANK,SEEPAGE PIT OR - d
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELDp P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO IMP NO./�/ ,30
� , JOB NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO. ROAD-PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE' _ -
OWNER'S PERMIT 8 1 00
AUTHORIZATION, TOTAL FEE � REIMBURSEMENT FEE netI HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S WEER NEW HOUSE SEWER
SIGNED THIS DAY OF 19—,27 CONNECT ADDITIONAL `
OWNER OR �. o BUILDING OR WORK
OWNERS AGENT _ ➢1 SEPTIC TANK,SEEP,PIT(S)
ADDRESS ndC�?a173 <tWfTA 9 1 t,0 7- • AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAVi I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY „
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES-,COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL` OWNER OF THE ABOVE
DESCRIBED RESIDENTI /ROPER.TY � BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(5) ❑ CESSPOOLS
OF PERMITTEE /// 1t,.6t'•�'�'` -��\
JOHN A LAMBIE, COUNT; ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG INSPECTOR
CK N O CKSrH "
ACO 4 4,8 1 ,NOV 21 _4 - 4:5 CJ M