HomeMy Public PortalAbout6312 GOLDEN WEST AVE_Sewer__ c
CAG"0.03
74A64ED APPLI CATION OR PERMIT
COUNTY OF IAS ANGEL FB SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINED
ENGINED
AND SAFETY DIVISION BUILDING
JOHN b L&MM rz_ CauxdT EnWMAD-W ADDRESS
WM IAH A JImo. Sup'l of amiam4
- . . LOCALITY -
H[1.RE/T
FOR APPLICANT TO -FILL IN
D[/CRIFTI H LOT NO ir4r4p
/ - OWNER
MAIL /
BLOCK TRACT ADD RI/D �(f
NO. OF 5LDG5, a
SIZE OF LOT NbW ON LCP ITY lr— / TiL. NO
URN OF DISTRICT NO. GROUP LAP
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rye- ■K PG
CONT'MACTOR .D •
ADDRESS 3CO ON DATA
L DQTH
CITY T[ STATIONL. NO. JJJ
- STAT[ MARHOL[RIFERINC[ }
R[OIST RATION NO. COUNTY OWER po.
No. DESCRIPTION OF WORK FEE TYPE OF cON CTIoH LIENGTH FROM
HOUSE SEWER CONNECTING TO Y. P.L M.L.TO P.L V
PU eL IC■EWER 45.00 P.C.NO.
6 FTIC A K.■ O[PTT OR
rITE AND/OR DRAINFI[LD 410.00 CO.IMr.NO. JOB NO.
HOU/[■EWER CONNECTING TO TRUNK PERMIT NO. ROAD PIERMIT
PRIVATE DISPOSAL SYSTEM 15.40
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT EAI1[l 1A10[IT R[ ORD.INE".NO. DAT[
WORK TO HOUSE■EWER 01.00
OVERFLOW/[[PAG[FIT.DRAINFIELD
[KTN.,CESSt OOL,DRYW[LLMANHOL[ 45.00
AL AIR ORA DO HWY, OR ST.WIO[NInG
/EWER OR DISPOSAL SYSTEM j3.00 /TAT[ENCROACHMXNT
FYIIMIT NO.
INDUSTRIAL
WAIT[APPROVAL
OWN>:ErS PERMT S 2 OD CHARGES
CONNECTION CHARD[FE[
AOTHOETLPiTION TOTAL FEE
I HAV[ AT THIS DAT[ A CONTRACT WITH Ti[ HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT TI-i[ ASOVE DESCRIBED pSl/TInG DWILLINO �T�T�
TO THE PUBLIC SEWER. APPROVALS DAT[, INSPE GNATUR[
SIGN¢D THIS DA F O_
OWNER OR NEW HOUSE S[W[R
OWNKTM AGENT CONNECT ADOITIONAL
BUILDING OR WORK
ADDRILB/
■[DTIC TANK,■@,PIT(/)
I HO2[SY AC KNOWLEDGE THAT I HAV[ R. THS■ APPLICATION AHD/OR DRAINFI[LD
AND STAT[ THAT TH[ ASOVE'15 CORRECT AND AGR[! TO COMPLY
WITH ALL COUNTY ORDINANCES SE AND TATLAW ULATINO
PLUMBING AND BEWERB. CESSPOQL ❑ DRYWE71. ❑
I HERESY CERTI AT I AM R R ISTRR AND/OR ALTER,RY PAIR,SEWER OR
LICENSED AS RE BY LOS GLEN OU STA OF SWAG[ OS
DISPAL SYSTEM
GLI FORN IA OR I AM TH[ AL [R F, AND I TO DISCONNECT PLUG AND
RESIDE In Ti V[ DESCRI■ RSSIII I RTY ASANDON HOUSE SEWER
S I O NATIJ IV ❑
OF P SACKFILL■Kr'1jLC TANKS
SER,PIT(/) LJ CESSPOOLS
AZTO ROBERT WOOD
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SUPERVISING MECHANICAL ENGINEER
7
Y.O. CNH
3480E3 DEC 1310 D 7.0 Q~ V
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