HomeMy Public PortalAbout6340 GOLDEN WEST AVE_Sewer__ APPLICATION FOR PERM-IT 1
a DWIS1ON OF BUILDING AND SAFETY SEWER—SEWAGIE, DISPOSAL
Dep-thent of qty Enghw-
Cocintl of Los Anwdow BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
m CASSATT D. GRIFFIN, SUr'T OP'BUILDING LOCALITY
NEAREST
FO cR0"ST.
"LEN' OWNER
DESCIIIPTIO LOT i
If
BLOCK TRACT HAIR 4 ,
ADDRESS C fig^-�-•C
NG.OF BLDGS. — CITY TEL. N0.
SIZE OF LOT 0t ON LOT
USE OF QI$TRICT NO._ ORti�P YAP
BUILDINGS
BK PG
CONTRACTOR
ADDRESS CONNF.CTIQN DAYA
STATION DEPTH
CITY TEL. N0. MANHOLE R CE
STATE LOWER
REGISTRATION No. Q COUNTY
NO. DESCRIPTION OF WORK FEE TYPE 0 CTIOY LENGTH FROM
HOUSE SEWER CONNECTIEG TO T. CU P.L. M.L.TO P.L.
PUBLIC SEWER 3.50
SEPTIC TANK,SEEPAGE PIT OR
FIT1t AAD/OR DRAIXFIHLD 3.00
OYERFIOW SEEPAGE PIT,DRAINFIELD P. C. NO.
HKTN.,CESSPOOL DRYWELL MANHOLE 2.00 CO. IMP. NO. JOB N0.
HOUSE SEWER COMMECTING70
PRIVATE DISPOSAL SYSTEM s 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q j t.00 PERMIT NO. -
ALTER,RtPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 11.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
ovil H'8 PEMMT s 1 00
AUTHORIZATION TOTAL FFA REIMBU■RSE�MENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN ED COX- ruOVAI.S DATE IHSFECTOR EDIGXATUkE
TRACTOR TO CONNECT THE ABOVE DESCRIBED VISTINO DWELLING
TO THE PUBLLC SEWER. NEW HOUSE SEWER -
SIGNED THIS OF 19 -CONNECT ADDITIONAL
OW-NE-R OH '(7J/ UILDIXG 0 WORK
OWNXRS AGENT SEPTIC TANK,eEEP,PITS))
ADD ..i AMD/OR DRAINFIELD
1 EB
HERT ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CEEB POOL❑ DRYWELL❑
AND STATE THAT THE ABOYE IS CORRECT AND AGREE TO COYPLT
WITH ALL COUNTY ORDINANCES AND STATE LAWS,REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEDERS. SEWAGE DISPOSAL SYSTEM '
1 HEREBY CERTIFY THAT I AY PROPERLY R ED AND/OR DISCONNECT PLUG AND
LICEMBED AS REQUIRED BY OS ANG CO AND STATE OF ABANDON CT PLUHOUSE G AND
CALIFORNIA OR THAT I THE GAL W ER OF THE A YH
WER
DESCRIBED R DENTI PER TY. BACKFILL SEPTIC TANKS
SIGNATURE
SEEP.PIT($) ❑ CESSPOOL$
OF PER■ {r
JOHN A. LAMBIE ENGINEER � ROBERT A.WOOD.CHIE><PLBG, INSPECTOR
c1<. N.O, wR .p
!C 0 9 a� �4
Nz 7 4 4:J 0
°'e•'°
7aAesan APPLICATION FOR RMIT
COUNTY OF IAS ANGEL SEWER-SEWAGE DISPOSAL �.
DEPARTMENT OF COUNTY ENGI10M
BUILDING AND SAFETY DWISION fAl
I LD I M G
DRESSWoj_
a � CALITY
EAREST
OE CANT TO FJLL IN OSS
w r
TEL NO.
[ZEEOFLITO,
IOR X MAIL
TRACT MAILADDRESS
NO.OF BLDG&
OT NOW ON LOT CITY DISTRICT NO. GROUF It" PROclam BT
BI TOM CONNECT� TEL N0, STATION DEPT)lATE MAHHOLZ REFERENC[GISTRAnoN No. counrr
No. uuDggEEESCER�IPT 0 WOR FEE
PUBLICSSEWCONNECTING TO ;'
ElY TYPE OF CONNECTIO LENGTH FROM
SEPTIC T/�XK,SEEPAGE PIT OR T. CURB �, ■,L TO P.L
ITS AND/OR DRAINFIELD DO
OVEREEP
FLOW SAPIT,DR
X C P00 GE BRYW AINFIEL.D
$2.09
HOUSE SEWER CONNECTING TO P.C.NO. .
PRIYArE DIMSAI,SYSTE14 a $1,00Co. INP, No413 3 JOB NO.
WORK TOMM O ADUSIETISONALRBLDG.ORS1,00 TRUNK PERMIT X0. ROAD PERMIT NO.
T %EP�AI OREEXXAlIBEEAN N HOUSE STATE ENCROACHMENT
1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROYA
CHARGED
OWNEg.S PERMIT 2 00 CONNECTION CHARGE FU
AUTSOETLATION I TOTAL FEE RE-IMBURSEMENT FEE
I HAVE AT THIS DATE ACON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX13TINGNTRACT WITH THE HEREINAMED DWELLING APMOVAM DATE INSPE(fDR'9 SIGNATURE '
TO THE PUBLIC SEWER.
SIGNED THIS SAY OF i9_ NEW HOUSE!EWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
ADDRESSSEPTIC TANK,SEEP.PIT(2)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE 'SHAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE AEOVE IS CORRECT AND AGREE TO COMPLY CE93POOL El DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEINER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL ER OR
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REpU1RED BY L03 ANGELES COUNTY AN ATE OF ABANDON HOUSE SEWER
CALIFORNIA �THATA L 0 OF H ABOVEDESCRIBED RBACKFILL 9EPTIC TANKSll
SIGNATURE SEEP•PIT 9 CESSPOOLS
OF PERMI
VALIDATION ROBFRT A. WOOD
Ci IL 0. cw JiUPERVIDINQ URCHANICAL X14CI1NXMit
V ti,�6 3 3 6 3 p 5.C, 0 L