HomeMy Public PortalAbout6223 GOLDEN WEST AVE_Sewer__ ' 24650 INSERTS
- CE8088.80 APPLICATION FOR PERIl�IIT
�eeeazu COUNTY OF LOS ANGELES SEWER-$FWA, ISPOSAL 1'
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu1LDIHG Z Z
ADDRESS
JOHN A. LAMBIE, County Engineer
' WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cgoss sT.
LEGAL _ -
DESCRIPTION LOT N0. i 'OWNER-,
MAIL
BLOCK TRACT 'ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW'ON LOT CITY " TEL NO. _
USE OF
gUlTR1CT N0.I GROMAP I PG P E D BY
ICONTRACTO L[' - t' � d72
ADDRESS 3 CONNECTION DATA '
CITY TEL.N0. ® �� ON a DEPTH
7 Q / STATE MANHOLE REFERENCE- UPP
REGISTRATION NO. /Q 70 / [ COUNTY / dl -
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 12 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. URB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD t
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO x P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO 33 e_ --JOB N0. -
CONNECT ADDITIONAL BLDG-OR - y-) a
WORK TO HOUSE SEWER @ St 00 ;TRUNK PERMIT NO. ROAD PERMIT NO. V O
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT _ U
SEWER OR DISPOSA SYSTEM @ $100 PERMIT N0. O
INDUSTRIAL - R
WASTE APPROVAL 14
CHARGES y
OVTNER'S PERMIT S -2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE IT,Q� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIB-ED _WSTING DWELLING .APPROVALS DATE INSPEC OR'SSIGNATURE
TO THE PUBLIC SEWER. _ -
SIGNED THISY F 19_ NEW HOUSE SEWEROWNER OR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
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 SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY T T AM.PROPERLY REGISTERED ND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRE LOS ANGELES CO NTY AND ATE OF, ABANDON HOUSE SEWER
CALIFORNIA OR THA AM THE LEGAL 0 ER OF E ABOVE
DESCRIBED RESIDEN P RTY, BACKFILL SEPTIC TANKS ❑
SIGNATURE y SE P PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
Or VALIDATION ROBERT A. WOOD
Cc M.o, a SUPERVISING MECHANICAL ENGINEER
io 6 €3 0 5.0
24650 INSERTS
CEAPPLICATION. FOR PERM T
ae
�eA6azD COUNTY OF LOS ANGELES SEWER—SEWAGE D1,AP4PSAL �^
DEPARTMENT OF COUNTY ENGINEER
'BUILDING
BUILDING AND-SAFETY DMSION ADDRESS
JOHN A. LAMBIE, County En neer
WILLIAM& JENSEN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN caoss ST.
LEGAL
DESCRIPTION LOT N0. - OWNER _
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS_.
SIZE OF LOT NOW ON LOT / CITY TEL NO. ,
USE OF ���
USEBUILDIN DISTRICT N0. ROUP MAP PCES BY
/ P
CONTRACTOR
igo
ADDRESS fJ a CONNECTION DATA -
CITY _TEEL.NO. ION DEPTH
REGISTRATION NO y COUNTY - NHOLE REFERENCE��1 �/ f UPP
No I DESCRIPTION OF WORK FEE / o
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FR M
SEPTIC TANK,
PITS AND/ORD AENFGELDT OR @ $3 00 Y. CURB P.L. M.L,TO P.L.
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. �•:� JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT N0, r/ a
WORK TO HOUSE SEWER •@ $1 00 O 149
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 03
SEWER 0 1SPOSAL SYSTEM. @ $100 PERMIT N0.
INDUSTRIAL - j
WASTE APPROVAL tal
CHARGES tail
OVVTNER'S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I REIMBURSEMENT FEE
,I HAVE AT MED CON-
TRACTOR TO CONNECT-S DATE AHE ABOVE T DESCRIBED EXISTING WITH THE HEREI-N ADWELLING APPROVALS DATE _ INSPECTOR'S SIGNATURE
TO THE,PUBLIC SEWER.
SIGNED THIS OF 19_- NEW HOUSE SEWER`
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I -HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 1 • w • - -
AND STATE THAT THE,ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALT ER,REPAIR,SEWER OR _
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY r4AT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIR LOS ANGELES COUNTY AN STATE OF DISCON N DISCONNECT
SEWER -
CALIFORNIA OR TH AM�THE OWNER 0 THE ABOYE
DESCRIBED RESIDE PROPERTY. ♦� BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS) ❑ CESSPOOLS ❑
OF PERMITTEE
®� VALIDATION -ROBERTA. WOOD
¢K, Y o, CASR SUPERVISING MECHANICAL ENGINEER,
us61 D - 5.00 ° -