HomeMy Public PortalAbout6306 GOLDEN WEST AVE_Sewer__ 7G[Df APPLICATION FOR PERM
7SAB41D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
IIEPARTb[ENT OF COUNTY ENGINEER
BlIUMING AND SAFETY DIVISION ■U ILDING
JOHN A. AgbxSw ADDRESS
WILLIAM A. JENSE , Sup'/ Ot BuEbdin4
LOCALITY
NEAREST
FOR APPIM TO ' IN c"NS BT•
D[NCRIPTION LOT NO. / OWNER
MAIL
BLOCK TRACTMd4ADORERS
NO. 010 ■LDGS.
SIZE OF LOT NbW ON LOT CTTY TIL NO.
BUIUBILDINGS
OF DIfTRICT M GROUP YAP PR BY
■UILDING■
■K r0 /
CONTMCTOR fro (',xy
ADDRESS CO CTI N DASA
CITY f TSL. NO. STATION D[TTH
STATE MANHOLE R[FER[NCI uPPQ
RSGISTRATION NO. Cou NTY LOWER
NO. DESCRIPTION OF W01;11< FIE TIT[OF CONNECTION LENGTH FROM
HOUR[SEWER CONNECTING TO Y CURE P.L Y. TO P.L.
PUBLIC SEWER 41 tp.00 P
SEPTIC TANK BEEP o[P oR 1 esI
O•
PITS AND/OR DRAINFI[LD 0 SIO.00
HOUSE SEWER CONNECTING TO THUNK IT NO. ROAD PERIHT NO.
PRI VATI DISPOSAL■YBTIEM 0 59.00
CON N[CT ADDITIONAL O. R AFFIDAVIT •AfY[1 RECORD.IND-TR.NO. DATE H
WORK TO HOUR[NEWER 0 $9.00 y
O VEIIFLOVIL6I[PAGE PIT,DRAINFI[LD L
".,CESSPOOL,DRYWELL..MAKHOLE 55.00
ALTER, HOUSE
HWY.OR WT.WIDENING
SEWER O f M /9.00 `« NTAT
jlooD_d JAV A"
[NCROACHMRfT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
WNM PEDUT- s 2 00
CONNECTION CHARGE FIR CHARGES
AUTHOMATIibN I TOTAL FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE NAMED AMED CON- REIMBURSEMENT F[[
TRACTORTO CONNECT THE ABOVDEBCRIMM L)(ISTIN4 DWELLING
TO TH[ PUBLIC BI WER. APPROVALS DAT[ IP(SPECTOR'A BIGNATU R[
E
SIGNED THIS DAY OF 42
OWNED OR KEW HOUSE SEWER
OWNUt1 AG[ CONNECT ADDITIONAL
_ f ■U ILDI NO OR WORK
ADD
1 H[R BY ACKNOWLEDGE THAT I HAVE RIFAD THI■ APPLICATION SEPTIC TANK,89".PIT(f)
AHD/OR DRAINFI[LD
AND STAT[ THAT THE ABOVE 1■ CORKS= AND AGREE TO COYPLY
WITH ALL COUNTY ORDINANCES AND STAY[ LAWS REGULATING
PLUMNING AND SEWERN. CESSPOOL ❑ DRYW[LL ❑
1 HERESY CERTIFY THAT AM IHIOPERLY AND/OR ALTER.REPAIR,S[WILR OR
LICENSED AS RIOUIRID OS AN NTY AND STAT[ SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I [ L[ L OW OF, A D INTEND DISCONNECT FLUG AND
RESIDE IN, TH[ ABOVE RIB RR.YID T ABANDON HOUSE SEWER
SIGNATURE SACKFILL XP-QC TANKS ❑
OF FERMI tT,P(T(S) u C[SSIPOOLS
A'j'I� ROBERT A. WOOD
CK. Y.O. H
SUPEQWSING MECHANICAL ENGINEF�R
CAT
Vtl 7 3 0 1.0 61 0 ' r.