HomeMy Public PortalAbout6344 GOLDEN WEST AVE_Sewer__ APPLICATION FOR PERMIT 1
•840�DIVISION
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OF BUILDING
,, AND SAFETY SEWER-S-EWAGE DISPOSAL
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,JOHN A. LAMBIE, COUNTY ENGINEER ADDRES'S
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REAREHT
FO CROSS ST.
LEGAL' - OIVNER
DE9CR1PT70 LOT N .
MAI E
BLOCK TRACTX. ` h DRESS
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NO.OF BLDG$.
SIZE OF LOT ; A V O NOW ON LOT CITY TELimmmmii. No-,,4
U! OF 1
BU L'INGS DISTRICT NO. GROUP SAP
' BK PG
CONTRACTOR
ADDRESS r COMfE=ON DATA
6TAT70 M DEPTH l
CITY TEL
M0. MANHOLEEFERENCE _
STATE WEA
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -?
OTYPE OF CTIOM LENGTH FROM
Y. P.L. Y.L.TO P.L
PUBLIC SfWIER a 3.50
S PTIC TANK,SEEPAGE PITOR
PITS AMD/OR DRAINFIELD S 5.00
OVERFLOW SEEPAGE PIT,DR,AINF
IEL.D - P. C. NO.
i EXTN.,CEBSPOOL,DRYWELL,MAXHOLE 2.00 CO. ITP. M0. JOB M0.
i HOUSE SEfER CONNECTING TO -
i PRIVATE DISPOSAL SYSTEM Q S 1.00 TRUNK PKRNIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEftER Q S 1.00 PERJIT NO.
ALTER,REPAIR OR ABANDON HOUSE
INDUSTRIAL
SEVER OR Dl P08AL BYSTE 1.00 WASTE APPROVAL
'4 CHARGES
I
'r CONNECTION CHARGE FEE
OWNEEVS PffiMTT S 1 00
REIRBURSEMENTFEE _
AUTHORIZATION TOTAL FM
I HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS- DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ADO YE DESCRIBED EXISTING PWELLIMG
TO THE PUBLICS MEW HOUSE SEWER
SIGNED THI F 19 CONNECT ADDFT19MAL
OWNER OR BUILDING OR WORK
OWNERS AG T SEPTIC TANK,SEEP,PIT($)
ADDR AILD/OR DRAINFIELD
I HEREBY AC OWLEDGE THAT I HAVE READ THIS APPLICATION CESSP00L❑ DRYWELL❑
AND STATE THAT THE ABOVE 18 CORREC-E AR AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. Self E DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AY PROPERLY R STERED AMD/OR DLSCONNE(;T PLUG AND
LICENSED AS REQUIRED BY LOS ANG CO AND, STAT OF
CALIFORNIA OR THAT AN THE O ER F HE VE ABANDON HOUSE SEWER
DESCRIBED RESIDENT PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURESSFP.PIT(S) CICESSP00
OF PERM
19
JOHN A- LAMBIE. Co ENGINEER ATION ROBERT A.WOOD, CHIRP•PLBG. INJSPXCTOM'
CIL X.0.
( 5 7 7 FEB 2 5 4
450 �