HomeMy Public PortalAbout6239 GOLDEN WEST AVE_Sewer__ ', 24650 INSERTS' �
76A642D80 APPLICATION,,-FOR PERMIT -
COUNTY OF LOS ANGELES SEWER-SEV1/14GE DISPOSAL -
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING '
ADDRESS
JOHN A. LAMBIE, County Engineer
WILLL4M A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS'ST. _
LEGAL
DESCRIPTION LOT N OWNER '
BLOCK TRACT ' ADD MAIL S -
N0.OF BLDGS, i _
SIZE OF LOT NOW ON LOT 'CITY TEL NO. �'
USE OFDISTRICT N0. GROU MAP
BUILDINGSPROCESS BY
• S
- PG
CONTRACTO .�R'� '�
ADDRESS !y - I NECTI )N DATA
CIT EL.NO, STATION 9 "1 DEPTH -
REGISTRATION NO! '(� G STATE MANHOLE REFERENCE• /1. ' LOWER _
y COUNTY '-/
NO. DESCR ON OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF ION ' LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR .Y. CURB• P.L. M.L.TO P.L.
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. —2� JOB N0.
CONNECT.ADDITIONAL BLDG.OR - TRUNK PERMIT NO. - yROAD PERMIT.NO. V
WORK TO HOUSE3SEWER @ $1 00 •�
ALTER,REPAIR O R ABANDON SYSTEM HOUSE @ $1 00 STATE ENCROACHMENTPq
SEWERPERMIT N0. _ O
INDUSTRIAL - U
•WASTE APPROVAL
P.
CHARGES - rn
OWNERS PERMIT $ 1 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Da REIMBURSEMENT FEE'
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- G -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE�' INSPECTOR'S SIGNATURE ,
TO THE PUBLIC SEWER. -
,
SIGNED THIS DAY`OF 19_ NEW HOUSE SEWEROWNER OR
OWNERS AGENT CONNECT ADDITIONAL '✓ _
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)• - - -
AND/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT 1 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 THAT I AM PROPERLY REGISTERED ASND/OR DISCONNECT PLUG AND.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR THAT 1 AM THE LEGAL OWNE OF THE ABOVE
DESCRIBED RESIDE L PROP R Y. BACKFILL SEPTIC TANKS ❑
SIGNATURE
_ SEEP.PITS) ❑ CESSPOOLS-Cl -
OF PERMITTE j
®r VALIDATION ROBERT A. WOOD 4 =
,' CIL R.o. OCAS/H / SUPERVISING MECHANICAL, ENGINEER i-