HomeMy Public PortalAbout6337 GOLDEN WEST AVE_Sewer__ ty� 650 INSERTS
6A642.60
7APPLICATION FOR PERMIT
6A842D COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION A"
U I LD I N G
ADDRESS
JOIiN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ` `� OWNER
DESCRIPTION LOT N0.
BLOCK TRACT + /�� MAIL
�G ADDRESS
OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP P6 PROC]BY
.� ✓j �/
CONTRALTO
ADDRESS CONNECTION DATA
CIT TEL.N0. STATION / DEPTH
REGISTRATION N0. STATE MANHOLE REFERENC,g �7
/ Q ` y COUNTY J C� LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 7 PE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y, -� CURB ) P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL, DRYWELL @ $2.00
HOUSE SEWER CONNECTING P.C.NO.TO CO. IMP.NO. - JOB NO.
PRIVATE DISPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. V
WORK TO HOUSE SEWER @ $1.00
SEWER REPAIR
SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0. O
1 NDUSTRIAL V
WASTE APPROVAL W
CHARGES V2
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE l REII HAVE AT DATE A CONTRACT WITH THE HEREINMBURSEMENT FEE
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENBUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH T I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID IAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
SIGNATURE
OF PERMITTEE
OF VAL SUPERVISING MECHANINCALO
CK. y..0. ENGINEER
o. CASR ,
U. 9 9 2 2 JUL 6 U