HomeMy Public PortalAbout6221 GOLDEN WEST AVE_Sewer__ J- 24650 INSERTS"
7GAe42D- APPLICATION FOR PERMIT,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL/ 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FADDRESS
DING
Yl14
IOHN A. LAMBIE, County Fs neat
WILLIAM A. IFNSEN, Supt of Building LITY -
EST 1
FOR APPLICANT TO FILL IN S ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAI LADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OFDI DISTRICT N0. GROU MAP PROCESSED BY
BUILDINGS /} A PG 140—
ADDRESS
CONTRACTOR ✓ 1 (/ I77 CONNECTION DATA
CITY C.T� TEL.NO. A ON DEPTH a
❑ SAT ANHOLE REFERENCE - _UPP
REGISTRATION NO ❑ COUNTY t
NO DESCRIPTION OF WORK
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.
y -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 -
HOUSE SEWER-CONNECTING TO ? ? �z�P.C.NO. _
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. / ✓ JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1 00 1 •TRUNK PERMIT N0. ROAD PERMIT N0. d O
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0. O
'INDUSTRIAL - €j
WASTE APPROVAL {q
_ CHARGES taq
OWNER'S PERMIT ow CONNECTION CHARGE FEE r3
AUTHORIZATION TOTAL FEE J REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE A OVE DESCRIBED EXISTDATE A CONTRACT WITH THE IINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS OF 9____ NEW HOUSE SEWER
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 AB VE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL El '
WITH ALL COUNTY OR ANCES AND STATE LAWS REGUL-TING ALTER,REPAIR,SEWER OR
PLUMBING A/V�ERVSEWAGE DISPOSAL SYSTEM
t• HEREBYTHAT 1 AM PROPERLY REGISTERED AND/ORDISCONNECT PLUG ANDLICENSED AED BY LOS ANGELES COUNTY AND ATE OF -ABANDON CTULUGANDSE 'CALIFORNIAT 1 AM THE LEGAL OWN R OF T E ABOVEBACKFILL SEPTIC TANKSDESCRIBED PROPERTY. a SE .FIT(S) CESSPOOLS,(3 -
SIGNATURE ' '
OF PERMIT \ ' r
®P ATIO ROBERT A. WOOD
C& s.°. kTH . SUPERVISING MECHANICAL (ENGINEER, "
- 0 7 9 juL �7 1 1 n 2 5.0 0
24650•INSERTS•
.,76A642DH0 APPLICATION O®R 4ERMIT'' - e
COUNTY OF LOS ANGELES SEWER—SE. .A1GE .DISPOStIAL 1
DEPARTMENT OF COUNTY ENGINEER ' -
BUILDING AND SAFETY DIVISION FA"Ul'LREJOHN A. LAMBIE, County EngineerWILLIAM A. JENSEN, Sup'! ofBuilding cSM FOR APPLI ANT TO FILL IN .
LEGAL - - -
DESCRIPTION LOT NO. OWNER;
BLOCK TRACT MAIL
• `ADDRESS - ./'
NO OF BLDGS. "
SIZE OF LOT NOW ON LOT / CITY TEL NO A
USE OF DISTRICT NO. GROUP MAP P ES BY "
BUILDINGS /' B PG
CONTRACTOR
r
ADDRESS 'Z Q. I/ ,C NECTION DATA
CITY TEL N ION DEPTH O
TATE AN OLE REFERENCE
REGISTRATION N0. COUNTY o (/
NO DESCRIPTION OF WIDRK E
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM ?,�
SEPTIC TANK SEEPAGE PIT OR Y. CURB L. M.L.TO P.L. ..J�
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 N0. 11?3 JOB NO.
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO. 0
U
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 °STATE ENCROACHMENT
PERMIT NO, 0
INDUSTRIAL V
WASTE APPROVAL W
CHARGES a1
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ _
TRACTOR TO CONNECT THE ABOVE ESCRIBED EXISTING DWELLING APPROVALS DATE INSPEgo SIGNATURE
TO THE PUBLIC SEWER. 'SAA
SIGNED THIS D Y 9- NEW HOUSE SEWER D -
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 THA TH ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL E3 DRYWELL ElWITH ALL CO T RDINANCES AND STATE LAWS REGULATING - ALTER,REPAIR,SEWER OR
PLUMBING AN S S - SEWAGE DISPOSAL SYSTEM
1 HEREBY C T Y THAT I AM PROPERLY REGISTERED ND/OR DISCONNECT PLUG AND
LICENSED S UIRED BY LOS ANGELES C TY A D ATE OF ABANDON HOUSE SEWER '-
CALIFORN T AT 1 AM THE LEGA BN
ER 0 E ABOVE
DESCRIB - 1 TIAL P OPERTY. SACPFPIT(S)P❑ CESSPOTANKS OLS ❑ -
SIGNAT R
OF P IT zi
®� ALIDATIO RORERt A. WOOD
CK. .m.o. CAsm SUPERVISING MECHANICAL, ENGINEER-
JUL 5 .0 0