HomeMy Public PortalAbout6256 GOLDEN WEST AVE_Sewer__ IVY
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75AOUaAe4to APPLICATION FOR PERM
�1COUNTY OF LOS ANGELES SEWE —SEWAGE DISPOSAL
DtPARTbUM OF COUNTY ENGINEER SEES
BUILDING AMID SAFETY DIVISION ■UILDING
TORN IL 1[QTR. Co=ty Em4alneor ADDRW
W L AM JL JENSEN, Sup'f of b-tld+a4 G'
LOCALITY
H[A R[LT
FOR APPIWANT TO CROP/ ST.
OWNER A
DESCRIPTION
MAIL A---N
BLOCK TRACT ADDRESS
OF 19I.DG S.
SIZE OF LOT NOW ON LOT CITY TZL. NO.
YB[ OF DISTRIW.mou"
MAl PROCES fY
3 ILDING■
■K ro
CONTRACTOR le-1 ,
ADDRESS Ir G CONNECM IYATA
CITY TCL NO. / 1O DEPTH
5TATX MANHOLE REF[R[NCE F
R[OISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE TY of ION ENG-H FROM
HOUSE SEW<R CONN[(.TING TO PA_ M.L.TO P.L.
PUBLIC■EWER $5.00
■[DTIC TANKS EPAGE Pff OR U p Np, O
PITS AND�OR DRAF+i FIELD SIb.00 CO.IMP.NO. (J
HQUSE S[W[R CONNECTING TO TRUNK PERMIT NO. ROAD PERMI 9w
E P
PRIVATE DIBOSAL SYSTEM S*.00 O
CONN[
HAD DITTO AL .OR AFFIDAVIT TAMER lAIULET R[CO R D,INBE
fl-TR.N DAT
WORK TO OUSE LD OSEWER $7.00
OVERFLOW S[CPAG[PIT,DRAINFIELD
EXTH.,C EISPOOL,DRYWRLMANHOLE $5.00
ALTILR.R A R OP AbANDOm HoUibitRNII'.OR/T.W I N
■[W[R OR DIBNOSAL SYSTt.M Q $3.00 STATE ENCROACHMEM
PERMIT NO.
INDUSTRIAL
PERMIT 2 00
WASTAPPROVALAPPOVAL
CHAR0ES
OWNER'S s
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE F[[
'IHAV[ AT THIS DAT[ A CONTRACT WITH THE HER[ ND
I AMECOM- R[IMBURL[MENT FEE
TRACTOR'To CONNECT THE ABOVE DESCRIBED EXISTING DWELLINQ
TO THE PUBLIC SEWER. APMOVAM
DAT[ INSP[ OR'S SIGNATURE
SIGNED THIS DAY OF 12_
OWNER ORNEW HOUSE SEW MR
OWNERS AO[NT CONNECT ADDITIONAL
■U ILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOW L[DG[ THAT ( HAVE -READ THIS APPLICATION AND/OR DRAINFI[LD
AND STAT[ THAT THk ABOVE IB CQ
AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWtLL ❑
1 HEREBY CERTI T I AM PROPER REGISTERED AND/OR ALTER,REPAIR,■[W[R OF1
LICENSED AS R BY LOS G C LINTY A STAT[ OF SEWAGE DISPOSA L SYSTEM
CI�LIFOIINIA O AT AM T TL R OF, INT[Np TO DISCONNECT PLUG AND
R ESID[ IN, H ASO ESC R TIAL RTY, ABANDON HOUSE SEWER
■IGNATURY BACKFILL SEPBC TANKS ❑
OF PEHMI SE Q.PIT(S) U CESw-OOLJ El
VALIDATION ROBERT A. WOOD
C
M.0. CALF{ SUPERVISING MEECHANICAL HNGINEER
V 05 0 5 01 JAN30 1 0 D 7.0 0-
ceeoe,0
7eAe42D -ea APPLICATION FOR PERMIT
u
COUNTY OF LOS ANGELES SEWER SEWACt DISPOSAL
DtPARTM MT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING e
0ffi( J.. T1LI11Tp._ Caunty ]?y
W IAM JL �, ffuVt of � ADORE"
v
LOCAL TTY
NEAREST
FOR CANT TO FILL Dj CROS OT.
DESCRIFTION L OWNER
MAIL
■LOCK APDR[D./
■.
■IZI OF LOT CITY TEL. NO.
UEE 0I DISTRICT NO. wOUP MAr P /Y
bUILD,F ■K PG
CONTRACTOR IVi
ADDRESS �� CONNECTION DATA
ON DEPTH
CITY NO.
2AT" MANHOLE REFERENCE
REGISTRATION NO. COUNTY OWER
NO. DESCRIPTION OF WORK FEE TYpE c oN L[NOTH FRO
HOVSE SEWER CONNECTING TO P.L M.L TO F.L.
PUBLIC SEWER 41 65.00 F.C.NO.
S IC TANK.■ P O[PIT OR CO.IMP.NO. 73 JOS NO.
PITS AND/OR DRAT NFIELD •10.00
Ho UBE■EWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOGAL SYSTEM 0 47.00
CONNECT ADDITIONAk ELDO.014 AFFIDAVIT WAIT[[ LASLEER T
RECORD.INSR.NO. TI
E
WORK TQ HOUSE■ WER 47.60
OVERFLOW SEEPAGE PIT.DRAINFI[LD
E)CTN.,CES■POOLDRYWELLYANHOL[0 48.00 �0 4
L ,R A R O N O HWY. I �l
SEWER OR DI/ OGAL S M Q $7.00 STA E ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CNAROKS
OWNERS PERMIT s
AUTHORIZATION TOTAL FEE CONNECTION CHARD[F[[
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA r CON- RIIMEURS[M[NT FEE
TRACTOR To CONNECT THE ABOVE DESCRIBED LE 1/TING DW[CLING BT]T)flO\7RT0
TO THE PUBLIC SEWER. AM •LL1i1LrOO DAT[ INdT[cTOR'/SIONATLR[
HIONED THIS DAY OF iG_
OWNER OR NEW HOU?K$[WLR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRES/ @EPTIC TANK.SEEP,PIT(@)
I HERKEY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINPIELD
AND STAT[ THAT THE ABOVE I@ CORRECT AND AGREE TO COMPLY
H
WITALL COUNTY ORDINANCES AND 1TATE LAWS REGULATING
PLUMBING AND SEW CESSPOOL LlDRYWILL ❑
1 HERESY CERTI AT 1 AM PROP[ REGI@TERID AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS RE ■Y LO/ ANLL UNTY AN ATI OF ■LIMA G[DISPOSAL SYSTEM
CALIFORNIA OR AT AM THE GAL R OF, AH NTIND TO D14CONNECT PLUG AND
RESIDE IN, A■ DESC TIAL PR RTY. ABANDON HOUSE BKWER
SIGNATURE PLACKFILL fxIC TANKS ❑
OF PERMS ZEEP.PIT(S) u CWFOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. Y.O. C/1./H
5 0 5 1ZZ JAN 30 1 1 D 25.00- 19