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HomeMy Public PortalAbout6227 GOLDEN WEST AVE_Sewer__ TEMPLE�, WE -I ' � 79AG426 e1q.. CE800 8.59 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL } DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIQVIISION ineer ADDRESS - C�ATIHN AD.GRIIFFIN pt of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. D�— LEGAL DESCRIPTION LOT N . �� "' OWNER / MAIL BLOCK TRACT ADDRESS Q/YYuv NO.OF BLDGS. SIZEOF'LOT NOVO ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCES]BY ,, _ PG CONTRACTOR �'� ADDRESS 3 CONNECTI N DATA ' CITY S TEL.NO. © lef STATION_ PY 5,0 DEPTH - I STATE MANHOLE REFERENCE PP REGISTRATION N0. B COUNTY NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO - PUBLIC SEWER @ $3.00 TYPE OF- URBC TION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. P.L. M.L.TO P.L. ITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD - - ' EXTN. CESSPOOL. DRYWELL @ 82.00 HOUSE SEWER CONNECTING TO /, JOB NO. PRIVATE DISPOSAL SYSTEM - @ $1.00 CO.IMP. N0. CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO. f^ WORK TO HOUSE SEWER '@ $1.00 ' SEWER OR PAIRO R ABANDON SYSTEM HOUSE @ $1 00 STATE-ENCROACHMENT , PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMT $ 2 00 CONNECTION CHARGE FEE 'AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT DAATRACTOR TO CIONNECT THE ABO ET DESCRIBED EXISTWITH THE IJNGAMED DWE CIONG APPROVALS DATE INSPEC OR'S SIGNATURE TO THE PUBLIC SEWER. - SIGNED THIS DAYcliel / NEW HOUSE SEWER I OWNER OR CONNECT ADDITIONAL - OWNERS AGENT 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 1 HEREBY CERTIFY' T T I AM PROPERLY REGISTERED AND/OR. DISCONNECT PLUG AND LICENSED AS RE 1 Y LOS ANGELES COUNTY AN STATE OF ABANDON HOUSE SEWER 0 CALIFORNIA, 0 T AM THE LEGAL OWNER HE ABOVE DESCRIBED SI NT PROPERTY. BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS SIGNATURE OF PERMI ®r VALIDATIO ROBERT A. WOOD ^� C6 M G. CASH SUPERVISING MECHANICAL ENGINEER L.f'CO 9 6 7 5 JUL D