HomeMy Public PortalAbout6217 GOLDEN WEST AVE_Sewer__ ` �°2
78A642D842D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION DING
]OHN_A. LAMBIE, County Engufeer ESS /
WILLIAM A. JENSEN, Sup't of Building !�FA
LITYEST
FOR APPLICANT TO FILL IN FS ST
LEGAL
DESCRIPTION LOT NO {� OWNER
MAIL A157
BLOCK TRACT ✓J r ��' /./ CG, ADDRESS
_NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL ANO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
_ BK PG
CONTRACTOR
ADDRESS jf '— / S 7- CO ECTION DATA
CITY 1, TEL NO STATION DEPTH �/
/1 `/� �..i' /
f/ COUNTY MANHOLE REFERENCE ` UPPER
,REGISTRATION NO P
NO CESCRIPTION OF WORK FEEr
TYPE OF CONNECTION LENGTH FR
HOUSE SEWER CONNECTING TO - ` ^ Y CURB P L ML TO P L O
PUBLIC SEWER 00 V
SEPTIC TANK.SEEPAGE PIT OR P C NO lJ
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 44� O
PRIVATE DISPOSAL SYSTEM @ $300 '.l I.-
CONNECT ADDITIONAL BLDG OR gFFIDAVIT WAIV EN EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD N
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $500 Z
ALTER,REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL FEE �YY7 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- REIMBURSEMENT FEE
'TRACTOR TO CONNECT THE ABOVE DEN
_SC_RIBED EXISTING DWELLIG
TO THE PUBLIC SEWER APPROVALS DATE INSPECTO
R'S�1GNATURE
SIGNED THIS DAY OF 19
OWNER OR .+_ / NEW HOUSE SEWER
OWNERS AGENT y�f
CONNECT ADDITIONAL
- BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAT NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AWESC RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(5) ❑ CESSPOOLS ❑
VALIDATI01=/ ROBERT WOOD
CK M o (`CASH SUPERVISING MECHANICAL ENGINEER
A01 7 6 71 OU23 3 1 0 0 7.00-
4
�r.
r ~
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1002220007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE- (626) 285-0488 EXT•
ILEGAL ID ISEWER / SEPTIC SEWER I BUILDING ADDRESS
I ON FILE (EXIST OCC GRP 1 6217 GOLDEN WEST AV
I _IBLDGS NOW ON LOT I TEMP CA 917801705 1
(ASSESSOR INFORMATION NUMBER ICONNECTION TYPE NEAREST CROSS STREET: GARIBALDI 1
15385-021-026 (ORIGINATION I THOMAS PAGE 597 GRID A2 LOCALITY. TEMPLE CITY, Cl
I ILENGTH ML TO PL STATION: DEPTH I I
(TENANT- IMANHOLE REFERENCE UPPER/LOWER: 11SSUED ON PROCESSED BY EXPIRES ON 1
1 102/22/10 SR 02/22/11 1
1 ICOUNTY IMPROVEMENT NUMBER I
IOWNER TEL- N0. IPLAN CHECK NUMBER- iNAL DATE FIj�IBY CODE•
1 GARCIA, JOE - 1 JOB NUMBER y`I,(1V/
16217 GOLDEN WEST AV ITRUNK PERMIT NUMBER
ITEMP 917801705 IROAD PERMIT NUMBER: DESCRIPTION OF WORK • I
I IAFFADAVIT NO ISEWER REPAIR CLEAN OUT INSTALLATION
I (WAIVER: NO
(APPLICANT TEL. NO (EASEMENT- NO I
ISTEVE SANTIZO (310) 645-4680- 1 I 1
15761 UPLANDER WAY (RECORD INSTRUMENT NBR RECORD DATE ISPECIAL CONDITIONS
ICULVER CITY CA 90230 (HIGHWAY/STREET WIDENING 1 1
ISTATE ENCROACHMENT PERMIT NUMBER I
I I I I
(CONTRACTOR. TEL NO 1 FEES PAID (APPROVALS DATE INSPECTOR SIGNATURE
IRAPID PLUMBING (310) 645-4680- I 1 1
15761 UPLANDER WAY LIC NO IFEE DESCRIPTION QUANTITY- UOM- AMOUNT INEW HOUSE SEWER II I
ICULVER CITY CA 90230 771663 C36 *1 I
1 101 PERMIT ISSUANCE FEE 27 75 ICONNECT ADDITIONAL I 1
1 115 ALT/REP HOUSE SEWER 1.00 EAC 30 45 1BUILDING OR WORK I I 1
(ARCHITECT OR ENGINEER. TEL NO I TOTAL FEES 58 20 I 1 -1-1 I
- 1 ISEPTIC TANK, SEEPAGE PITI I I
1 LIC. NO 1 (AND/OR DRAIN FIELD I I 1
I I I I I
I 1
IDR LL _ 1
I I I I I
1 SEWER MAP BOOK PAGE. 1 (ALTER, REPAIR, SEWER OR 1 1
(SEWAGE DISPOSAL SYSTEM I
I I I I I I
- IDISCONNECT PLUG AND 1 I
I I 1ABANDON HOUSE SEWER I
I I I I I I
1 I IBACKFILL SEPTIC TANKS _1 1
ISEEP PIT _ CESSPOOL -1 I
I I I I I I
GRAYWATER SYSTEM I
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I 1* ADDITIONAL, DATA ON FILE I I I 1
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I IREPORT ID: DPR266 ROUTE TO BS0508
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