HomeMy Public PortalAbout6226 GOLDEN WEST AVE_Sewer__ E-6D
S E•663 12.54 - APPL [CATIO.M"TOR PERMIT ,
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE ®ISPOSAL.
Department of County Englneer
t County of Los Angeles TADDRESS
ING
WM. J. FOX, COUNTY ENGINEER.
CASSATT D. GRIFFIN, SUP'T,OF ISUILDING LITY
FOR APPLICANT TO FILL IN ESr
S ST:" I LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
NOF BLDGS. .'
SIZE OF LOT NOW
ADDRESSW ON LOT �� CITY TEL. N0. .�
USE OF 19
BUILDINGS DISTRICT N0. I GROUP I MAP
BK PG
CONTRACTO
ADDRESSCONNECTION DATA
D'
CITY - TEL. NO.' •STATION DEPTH -
STATE MANHOLE REFERENCE
REGISTRAONTIO. ❑ COUNTY .4 % �"�� _ LOWER
TYPE 0 ' ECTION LENGTH FROM �O
NO. DESCRIPTION OF WORK FEE °Ya CUR zmz:z- M.L. TO P.L.
HOUSE SEWER CONNECTING TO 9 A/� f7H v ��Da
'PU BLICSEWER - Q $, 3.50 .,.3 J,./_ ,
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO.CO. IMPJOB. NO.
NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING �p �/j*/ 7,
SEWER OR��DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0. v(�
DISCONNECT AND ABANDON SEWER, STATE,ENCROACHMENT
AND/OR DISPOSAL SYSTEM1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL -
CESSPOOL--DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PET CONNECTION CHARGE FEE
OvVNERIS $ 1 00
AUTHORIZATION TOTAL FEE- REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH HEREIN N MED- CON-
ITCTOR'TO CONNECT TH ABOVE DES D EXISTING DWELLING I APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SES
SIGNED THIS D Y NEW'HO USE SEWER ; ol
OWNER OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
ADDRESS' SEPTIC TANK, SEEP, PIT(S)-
AND/OR DRAINFIELD
• 1 HEREBY ACKNOWLEDGE THAT I HAVE'READ THIS APPLICATION CESSPOOL ElDRYWELL'❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,,REPAIR, SEWER OR
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE-DISPOSAL SYSTEM -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PL'UG•AND
CALIFORNIA-OR THAT -1 AM THE LEGAL' OWNER OF THE 'ABOVE ABANDON HOUSE-SEWER
ESCRIBED R IDENT AL PROPERTY. -
/ Q BACKFILL SEPTIC TANKS❑
G �i y SEEP. PIT(S) ❑ CESSPOOLS
G�l AT
UR a
OF PERMITTEE - -
WILLIAM J. FOX.-COUNTY ENGINEERVALIDATION
oa 214a 4 4,50
'BY - By
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