HomeMy Public PortalAbout6233 GOLDEN WEST AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER ! SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I ADDRESS -2 3J
G FOR APPLI�ANT TO FILL gN - S LOCALITY
IUILDINGADDRENEAREST
SS �?�Q� ``{�f/gam �'f CROSS ST. ll
LOCALITY�',eMp r DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST ! - t ' A ��� S
CROSS ST. /SO A/Lif a G��Int
I RE IV B Ready for Inspection kATE 1 UED
OWNER � �I�. 'T�®IPS SG�►/\�
MAIL _ USE ZO OCCUPANCY MAP
ADDRESS U 4��'�•sF� � BK PG
CITY TEL.NO. - f I Z_ 7P
CONTRACTOR � `�����
_ CO.IMP.N0. / 3
ADDRESS d`
e� JOB.NO.
CIS TEL.NO �j.-f TRUNK PERMIT NO.
q —STATE
R E G I S T R T10N N0. ��. H COUNTY ROAD PERMIT NO.LEGL
DESCRIPTION LOT NO. / � �Cj 7e'l// B d-Of �► STATE ENCROACHMENT b
PERMIT NO.
BLOCK tl� TRACT !;Ah1e,4 hqA;j Ifr4 INDUSTRIAL
_ WASTE APPROVAL
SIZE OF LOT ,� y �y
y ��V NOW ON LOT / CHAR
USE OF N0.OF Bl-DGS. G
BUILDINGS CONNECTION CHARGE FE
NO. DESCRIPTION OF WORK FEE REIMBURSEM ENT
9 HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 ";z6-0 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION 4CORDED
WORK TO HOUSE SEWER 1.00 0
ALTER OR REPAIR EXISTING DA BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM Loo CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION
DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 NHREFERENCE
LOWER
YPE OF CONNECTIO LENGTH FROM f�
Y. _ M.L.TO P.L. ��,�
OWNERS PERMIT $ 1 414-6,
11 00
AUTHORIZATION TOTAL FEE I 4-6, -
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PU13LIC SEWE_.._R
SIGNED THIS-_____ .---DAY OF_ __�✓� _ NEW HOUSE SEWER�__...__._ _.__19:��__� _
OWNER OR � � _ CONNECT ADDITIONAL
//���� ......----_............ BUILDING OR WORK
OWNERS AGENT_. .t_fC! ._
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........I......-........ - .......--w....•--------. ----•-.w..... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL-E]
CA
TIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAI.SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Ej
SIGNATURE
SEEP.PIT(S)E] CESSPOOLS E]
OF PERMITTE --- ---- -_ �-....__. .._.....- -.._.
76AG42D 663 Ut63
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