HomeMy Public PortalAbout6257 GOLDEN WEST AVE_Sewer__ DEPA19126ElvT OF 0OU7gW ENCM= SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUM.DING AND SAFETY PERMIT APPLICATION
OOUNT!V OF IAS ANGELES
WILLIAM J. FOX, CouwrY ENOINEOZ BUILDING
ADDRESS .7 Q �(I
R APP IN LOCALITY r Gr
BUILDING NEAREST
ADDRESS CROSS ST .Ole[/
LOCALITY
• DISTMOT NO. SERIAL NO. PERMIT NO.
NEAREST ,t - A --IS
CR088 ST.
RHCEIV Reams for I"pwdq DATE I HD
OWNER /
MAIL 8E SONE OCCUPANCY ADDRESS r�J\//J B!( PG
CITY TEL 0. �'�
CONTRACTOR OO.IMP.N0. 133 a -7 - 19
ADDR JOB.N0.
OI NO. TRUNK PERMIT NIL
REG18TRATION NO. a COUNTY ROAD PERMIT NO.
I LEGAL
DESCRIPTION LOT NOO r L..ti" STATE ENCROACHMENT
PERMIT N0.
BLOCKAI
TRACT INDUSTRIAL
+ WASTE APPROVAL
SIZE OF LOT 3 0.OF BLOTS CHARGES
OW ON LOT
USE OF
BUILDINGS f, , s CONNECTION CHARGE FE
NO. DESCRIPTION OF WORK FEE
HOUR SEWER NE IN TO REIYBUR8EYEKr FEE
PUBLIC SEWER 1 &H RECEIPT NO. DATE BY
HOUSE SEWER DONNEGIINGro
PRIVATE DISPOSAL SYSTEM 1.00
r,oNNEOT AbblYIONAL BLbtL OR PTION EOORDED
WORK TO HOUSE SEWER 1.0E N
A TER OR REPAIR EXISTING DAllfBY
SEWER OR DISPOSAL SYSTEM I.00
D1800NN 9 Of AND ABAN ON EWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PtAr OR
PITS AND ORDRAINFIELD 2.60 STATION D DEPTH
CESS ELL
SPECIAL CONDITIONS ONLY 2_00 / AIIHOLE REFERENCE
�i E
TYPE OF OTIC LENGTH FROM
Y.L TO P.L
OWNERS PERMIT ; 1 00
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO T E UBLIO BEWEFkQL
SIGNED THIS AY OF 9 NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR
OWNERS ABUILDING OR WORK
GE
SEPTIC TANK,SEEP.PITH)
B
ADDRESS-- ND ODRA NFIELD
I HEREBY AOKNOWLROGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ 011"ELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR S WER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPO SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AN THE LEGAL OWN- ABANDON HOUSESEWER
ER OF THH E DESCRIBED E81 I BOPERTY. AN [] •
SEEP.PIT(S)❑ CESSPOOLi�
SIGNATURE 1
OF PERYITT
TU642D 663 Eolf63 Lor