HomeMy Public PortalAbout6219 GOLDEN WEST AVE_Sewer__ 246050 INSERTS "
,CE808 6-601A.PPLIOATI O N, FOR R PE
'76A642U RM • `
COUNfY'OF LOS ANGELES SEWER-SEWAGE ®ISPOS�►L 1"
DEPARTMENT OF•COUNTY ENGINEER
Y BUILDING AND SAFETY DIVISION ADDRESBUILDIS G 67-11
JOHN A. LAMBIE, County Engineer r
WILLIAM A. JENSEN. Supt of Building LOCALITY
.NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO OWNER G
BLOCK TRACT MAIL
ADDRESS
` NO OF BLDGS. '
SIZE OF LOT NOW ON LOT / CITY TEL NO
USE OF
BUILDINGS d� DISTRICT NO. GROUtj MAP PG ,PROCESS BY
_3 4 B
CONTRACTOR n
ADDRESS .CO CTIO ATA
CITY G TEL.NO. O ON DEPTH
�J ❑
REGISTRATION N0. ST E `MANHOLE REFERENCE y UP
`'J ❑ COUNTY a �, -
No DESCRIPTION OF WORK FEE'
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 V�, TYPE OF CONNECTION LENGTH FROM -
SEPTIC TANK,SEEPAGE PIT OR T. CURB 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. JOB NO.
rk
CONNECT ADDITIONAL BLDG OR ,TRUNK PERMIT N0. ROAD PERMIT NO. a O
WORK TO HOUSE SEWER @ $100 U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO Q
INDUSTRIAL - U
WASTE APPROVAL µl
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE -
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - APPROVALS D TE INSPE TOR'SSIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS D Y 19_ NEW HOUSE SEWEROWNER OR = 3
OWNERS AGENT- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD _
I HEREBY.ACKNOWLEDGE THAT 1, HAVE, READ THIS APPLICATION - - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL-El DRYWELL '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING ND WERS. - SEWAGE DISPOSAL SYSTEM
LDESCHERE E TI FY THAT I AM OPERLY GISTERED AND/OR
ENSE S QUIRED BY LOS ELES CO TY AND STATE OF DISCONNECT PLUG AND - a
LI FO A THAT 1 AM TH GA NER OF THE ABOVE ABANDON HOUSE'SEWER '
D IDENTIAL PROPE Y. BACKFILL SEPTIC TANKS T - S P. PIT( ) ❑ CESSPOOLS ❑F M TTEE
®� VALIDATIOI�T ROBE . WOOD
- CR. M.o. ( CAS /) SUPERVISING MECC HANICAL ENGINEER -
24650"INSERTS•,
CE8088.80, APPLICATION FOR PERMIT-: . 1
78A842D, COUNTY OF LOS ANGELES - SEWER-SEWAGE DISPOSAL .1
DEPARTMENT OF COUNTY ENGINEER' .BUILDING y/
BUILDING AND SAFETY DIVISION ADDRESS'
JOHN A. LAMBIE, County Engineer b �- �,_; �y�•
WILLIAM A. JENSEN. Sup't of Building LOCALITY
NEAREST
FOR APPLICANT -TO FILL IN CROss sT.
LEGAL '
DESCRIPTION LOT N0. TOWNER' -
BLOCK TRACT 'MAIL ,
ADDRESS,
NO OF BLDGS.
SIZE OF LOT NOW ON LOT ,CITY TEL. NO.
USE OF DISTRICT'NO. GROUP MAP PROCESSED BY
BUILDINGS
1 BI( PG
CONTRACTOR u
r --
ADDRESS CONNECTION DATA
CITY TEL.N0. 7 TION DEPTH
�,
,� / STATE MANHOLE REFERENCE �• de
REGISTRATION N0. Y e COUNTY O
No. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELDEXT ,
HOU CESSPOOL DRYWELL @ $2 00 �P.C.N0:
HOUSE SEWER CONNECTING TO CO IMP, NO JOB N0.
PRIVATE DISPOSAL SYSTEM @ $1 00
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT N0. Q Q
WORKTO HOUSE SEWER @ $I 00•SU
YSTEWER REPAIR
SAL ABANDON HOUSE @ $I 00 STATE ENCROACHMENT ,
PERMIT NO m
O
INDUSTRIAL
WASTE APPROVAL W
CHARGES vpi
OWNER'S PERMIT /�,q� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE v V REIMBURSEMENT FEE
I HAVE,AT DATE A CONTRACT WITH THETRACTOR TO CIONNECT THE ABOVE DESCRIBED ❑
RIBED H STI�NGAMED DWELLING ' APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS Y CIF 19= NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL '
OWNERS AGENT •BUILDING OR WORK -
ADDRESS SEPTIC TANK,SEEP.PITS)
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 LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWS SEWAGE DISPOSAL SYSTEM
I HEREBY CE T THAT I AM PROP Y REG STERED AND/OR DISCONNECT PLUG AND
LICENSED AS IRED BY LOS ANG COUN _AND STATE OF _
CALIFORNIA THAT 1 AM THE OW R OF THE ABOVE 'ABANDON HOUSE SEWER '-
DESCRIBED SIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ '
�—
SIGNAT SEEP PIT(S) El CESSPOOLS
❑ _ -
� �
OF P IT
®P VALIDAT 64, � ROBERT A. WOOD
CIL m 0. CASR/J ' SUPERVISING MECHANICAL ENGINEER
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