HomeMy Public PortalAbout6274 GOLDEN WEST AVE_Sewer__ t
7BA84
lo-8J APPLICATION OR PERI
�eAe4zD MT
COUNTY OF LOS ANGELES SEWER—SEWAGE PISPOSAL
D$PARTMENT OF COUNTY ENGINEER
B=ING AND SAFETY DIVISION BUILDING
w�OHH A. T lTF- 7 En Bir ADDRESS
L l A. IExaEH, Bnp t of sM'
LOCA L ffY
NUR[1T
FOR APPLICANT TO FILL IN 2 `R°" BT
DESCRIPTION LOTHO" 4p
OWNER
MAIL
■LOCK TRAC� ')\DDRESI
NO. OF BLDGS. �.
SIZE OF LOT NQW ON LOT CITY TEL NO. 1.
USE
OF DISTRICT NO GROUP MAF PROCESSEDj
BUILDING•
BK FO
CONT
CTOR /
ADDRESS CONNECTION DATA
STATION
CITY / PLL. NO. DEPTH
STAT[ UPPER
REGISTRATION NO. MANHOLE REFERENCEId
No. DESCRIPTICINOF WORK FEE TYPE of c ION LENGTH FROM
HOUSE SEWER C NN ECTING TO Y. CU P.L MA_TO P.L.
PU SLIC REW[R SB.00
•[DTIC TANK, FAO[PIT OR P.C.NO. (1
FITS AND/O DR INFIELD [10.00 CO.IMP.NO. JOS NO. / VY
HOUSE S[W�R C NECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRI VAT[DI■ SYSTEM S3.00 l O
CONNECT A DITI NAL BLDG.O AFFIDAVIT RECORD.INSTR.NO. DATE 0
WORK TO H USE EWER $3.00
OVERFLOW INALP E PIT,DRAINFIELD
[)[TN..CESSP OL, RYW[LL,MANHOLE $5.00
AL R PA 0 N O HWY.OR ST.WIDENING H
■[W[R OR DI ALAYSTCM •7.00 STATE ENCROACHMENT
'tRMIT NO.
INDUSTRIAL
�����+.pp WAST[APPROVAL
O`�=�1Y1\ is PE$I�IIT i 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FE[
'I HAVE AT THISDAT[ A CONTRACTFE
WITH THE HEREIN N MID CON- REIMBURSEMENT E
TRACTORTO CONNECT THE ABOVE DESCRIS[D LXISTINO DWLLLINO
TO THE PUBLIC SEINER. APPROVALS TE INsr[CTO n'S SIGNATURE
81CiNED THISDAY OP to_
OWNER OR NEW HOUSE SEWER
OWNER/AGENT CONNECT ADDITIONAL
■UILDING OR WOK
ADDRESS R
SEPTIC TANK.SEEP,PIT(S)
I 11"KBY ACKNOWL[DOR THAT I H READ THIS APPLICATION AND/OR DRAT N FIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH ALL CO ORDINANCES AND STATE LAWS REGULATING
PLU MSINO AND 1[W[RD. CESSPOOL ❑ DRYW[LL ❑
I HERESY CERTIFE
Y I AM PROPERLY n RCD AND OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUIR Y LOS A AND STA OF BEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA AM TH[ ALO D 1 TO DISCONNECT PLUG AND
RESIDE IN, A DESCRI D TI ABANDON HOUSE SEWER p
■1G NATURE BACKFILL S�lb.0 TANKI
OF P[n�1 S[[P, .'IB) LJ CESS P.O
ATIO ROBE • A. WOOD
SUPERVISING MECHANICAL ENGINEER
Y.O. CASH
i� 0 7 6 j`,l 21 1 0 D 7.00-1