HomeMy Public PortalAbout6277 GOLDEN WEST AVE_Sewer__ r& -669 11.68 C
SAPPLICATION FOR PERMIT 1
BE-8
DIVISION OF BWLDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
T) CASSATT D. GRIFFIN, SUPT OF BUILDING
LOCALITY L
NEAREST ry
FFORRAPPLIPAU;JO I.L I1�+. CROSS ST.
LEGAL /V
OWNER
DESCRIPTION LOT N0.
AIL
BLOCK TRACT DDRESS
/� NO. OF BLDGS. all CITY TEL. NO.
SIZE OF LOT SY"�/ NOW ON LOT �'KA-
USE OF / 0.
DISTRICT NO. GROUP MAP
BUILDINGS f. J PG
ey
CONTRACTOR K -/S �.. y 5
CONNECTION DATA
ADDRESS x �� .f,.l
I
STATION DEPTH
TEL. NO. 1
CITY - p MANHOLE REFERENCE PPER
JA STATE
REGISTRATION NO. ❑ COUNTY
No. DESCRIPTION OF WORK FEE
HTYPE OF ECTION LENGTH FROM
OUSE SEWER CONNECTING TO P.L. M.L.TO P.L.
]
PUBLIC SEWER @ $3.50 tj O Y. UR
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE Q $2.00 _C0. IMP. N0. f � ��, JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 _PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT t t 00 /. y
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE y
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS + Wi AND/OR DRAINFIELD
I HEREBY ACKN6WI1EDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGI ERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNW AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LE OW R OF THE A VE /
DESCRIBED RESIDENTIA OPERTY. BACKFILL SEPTIC TANKS❑ / .
SEEP.PIT(S) ❑ CESSPOOLS J9.5
SIGNATURE
OF PERMITTEE
JOHN A. LAMBIE. CO ENGINEER LIDATIONROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.0.