HomeMy Public PortalAbout6266 GOLDEN WEST AVE_Sewer__ 769644ii;. 1!-10-71 APPLICATION FOR PERMIT
COUNTY OF L08 ANGELES SEWER-SEWAGE DISPOSAL
bEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Mr—TYT—eol"
Q 16leTfFOR APPLICANT TO FILL IN V / /
D E/CRIFTION LOT NO. `� [ OWNER O/`/J 14,z—
MAIL
BLOCK TRACT ADDR1340040 v
NO. OF 11L.1009.
SIZE OF LOT NQW ON LOT I CCT' TEL NO.
U•[ OF /c `! DIDTRICT NO. •ROUP MAF SEDJBY
■U ILDINOS fV(J C cc A EE FJ
QONTTIACTOR N O TIS T� O ,DJ'QJ / D `
V f� 7/
ADDRESS pqvs Piz
-'/ /-�CCOPMCnON DATA
CITY I� �-{/ T'[L. NO. — / STATION �.L J-!� DEPTH
`IGEN.•[ NOS [TWO `L Z Lb AN I3 I MANHOLE REF[7RE�H/C�[J/ I ` � -R
Nb. PF-SCRIPTION OF WORK FEE TYPE OF c& ION LrMGT FROM
HOUSE SEWER CONNECTING TO o Y. ■ P.L M.L.TO P.L
PUBLIC/[woe ! $7.00
• FTIC TANK.sffpAoK PfT OR P.C.NO.
O.
CO.IMP.NO. JO■N
FIT/AND/OR DRAINFICLD ! 510.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT No. ROAD PERMIT NO.
PRIVATE DISPOSAL■YUTEM ! S3.00 O
CONNECT ADDITIONAL■ R AFFIDAVIT t mvLa [I1[ST RECORD.IN•TR.NO. DATE L)
WORK TO HOU;[BEW" ! 57.00
OVERFLOW/[[PAG[PIT.DRAINFIKLD
E)CTN..CE/SPOOL.DRYWELL ! [6.00 O
AL .R A ABANDO HOUSE HWM. OR ST.WIDENING
•[W[R OR DIBPOSAL SYSTEM ! 3.00 STAT[ENCROACHMENT
MANHOLE PERMIT NO. a
! X7.00 [/)
IN DueTRIAL Z
���7�� WAST[APPROVAL
O nl\L.il PEBDQC j 3100 CHARGES
CONNECTION CHARD[F[[
AIITHOffiZATION TOTAL r
1 HAVE AT THI; DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT�[E
TRACTOR TO CONNECT THE ABOVE DE■CRIBXD
TO THE PUBLIC /[W�fy APPEOVAIS DAT[ INS R'■SI TUR[
SIGNED THIS (( DAY OF tfl7) �(
OWNER OR KEW HOUSE/[WEA V
OWNER/AGENT CONNECT ADDITION
WILDING OR WORK
SEPTICADDR[Se
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
TANK.BEEP,PIT(e)
AND�OR QRAINFI[LD
AND BTAT[ THAT TH[ AeQVE is
CORRECT AND ACRE[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND /TATE LAWS REGULATING
PLU Me ING AND BEWERB. CUMPOOL ❑ -WELL ❑
I
HERESY CERTIFY THAT 1 AM PRO"RLY REGIST[ [ ERW
RD AND/OR ALT .REPAIR.SEER OR
LICENSED A& REQUIRED ■Y LO■ ANGLES CQUNTY AND STATE OF SEWAGE DISPORAL BYST[M
CALIFORNIA OR TH M TH[ LEGAL OW N[R F, AND NO TO DISCONNECT PLUG AND '
RESIDE IN, TH OV[ [SG IB<D R [NTS AeANPON HOUSE■EWER
BIO NATURE BACKFILL SEP7BC TANKS ❑
OF P[RM u
...P.IF cEB;Poou
VALIDATION CK. M.0. CASH
1i 060973 APR1710 D 10e04