HomeMy Public PortalAbout6251 GOLDEN WEST AVE_Sewer__ DEPAxTNOMv*r OF OOUNTY ENcONIMs SEWER—SEWAGE DISPOSAL 1
.IbMSION OF BUMDING AND SAFETY PERMIT APPLICATION
OOUNW OF 1,08 ANGST
WILLIAM J. FOX, COUNTY ENOIN[mBUILDING
ADDRESS
FOR APPLICANT TQ RA IN LOCALITY
BUILDINGNEAREST
ADDRESS I CRO ES ST.
LOCALn y, + DISTRICT NO. SERIAL NO. PERMIT N0.
NEAREST S Ate—. / 0 S
CROSS ST. pGpE�By Beat,fa IsspmtlN ZAISSUOWNER 1pJ _ C el
PAIL USE ZON BK OCCUPANCY
ADDRESS YAP a
PG
CITY
CONTRAOTO � T p OO.IMP.N0. !�
ADDp ii JOB.NO.
CI LNO. . ��Y
TRUNK PERMIT NO.
REGISTRATIO -4r ITL
COUNTY ROAD PERMIT NO. s
LEGAL
DESCRIPTION LOT N0. O.OYA44,4Z; STATE ENCBOACHMEIIT
PERMIT M0.
BLOCKAl TRACT INDUSTRIAL
�` WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS
USE OF NOW ON LOT CHARD r/'
fr
BUILDINGS CONNECTION CHARGE F
NO. DEEilffIRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CON E 0
PUBLIC SEWER Q >!N RECEIPT N0. DATE BY
HOUSE SEWERCONNECTIN
PRIVATE DISPOSAL SYSTEM IM
WWWtOT 1 ION L BL B.OC XCEPTIO ECORDED
WORK TO HOUSE SEWER 1.10
ALYIEft OR REPAIR EXISTING 0• D [ BY
SEWER OR DISPOSAL SYSTEM I.N
DISCONNECT AND AISANDON AEWER
AND/OR DISPOSAL SYSTEM L" CONNECTION DATA
APEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINF'
ELD 2JO STATION a. DEPTH
ELL
SPECIIAL CONDITIONS ONLY 2AKI Y P ER EFERENCE
TYPE OF ECTION LENGTH FROM 2 �--
OWNERS PERMIT $ I 1 Op M.L TO PA_ 315
AUTHORIZATION TOTAL HE D
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS IN8PECTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWE
SIGNED THIS DAY OF 9 NEW HOUSE SEWER (u,
CONNECT ADDITIONAL
OWNER OR
OWNERS AGENT BUILDING OR WORK
SEPTIC TA RAI SEEP.PIT(S)
ADDRESS— AMD ORDRA NFIELD
I HEREBY AOKNIW DGE THAT 1 HAVE READ. THIS APPLI- CESSPOOL E] DGYWELL�
CATION AND STATE T THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL UNTY ORDINANCEG AND STAT[ LAWS ALTER.REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOiA4SYSTEM
I HEREBY CERTIFY THATRE AN PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AY THE LEGAL OWN- ABANDON HOUGESEWER
ER OF THEA I fE DESCRIBED RWD9PTI ROPERTY. TANKS❑
S[EP.PIT(gE] CESSPOOLSv
SIGNATURE
OF PEpYITTEE
711ASUD 60 V /f}