HomeMy Public PortalAbout6354 GOLDEN WEST AVE_Sewer__ T
WIG"11-155as APPLICATION FOR PERMIT
s•M-
DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE D I S POSA L
Dopo t-W of Co=ly EaQ>t am
Comt7 of Los AII0Lf FIDDRE" f r
JOHN A. LAMBIE, COUNTY ENGINEER u� CABBATT-D. GRIFFIN, SUPT OF IBUILDING FOR APPLICANT TO FILL aos ST.
LEGALOXER -
DESCRIPTION LOT NO.
MAIL /
BLOC[ TRACT ! AI'DRE$B(/3r
NO.OF BLDG$.
SIZE OF LOT 2- MOW ON LOT CITYk"ev;-L- TEL. N0.
USE OF :I
BUILDINGS DISTRICT M6. V GROUP YAP
• BK PG
CONTRA CTO R
ADDRFJ9 9.�-Q CONNECTION DATA
DTA ION
DEPTH
CITY TEL. NO. `i j�Q .
MANHOLE REFERENCE UPPEY
❑ STATE 91
REGISTRATION NO. ❑ COUNTY
a
No. DESCRIPTION OF WORK FEE
HOUSE SEVER CONNECTING TO TYPE OF CTION LENGTH �
Y. P.L. Y.L.TO P.L.
PUBLIC SEWER (a 3.30 17-1
SK,EPTIC T SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q S.DO
OVERFLOW SEEPAGE PIT,DRAIMFIELD , IMP.N0. L JOB NOO;
EKTM.,C $POOL DRY, LL MANHOLE 1.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 YRUNK PERMIT MO. ROAD PERMIT No. f
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT 1
STORK TO HOUSE SEWER ! .00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
.SEWER OR DISPOSAL SYSTEM 14.00 1 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OVFNER�s PE IMT 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEF
I HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED COX- APPROVALS DATE INSPECTOQ'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED U19TING DWELLING
TO THE PUBLIC SEWER. _ NM HOUSE SEWER
SIGNED THg�u OF r, CONNECT ADDITIONAL
OWNER 0 BUILDING OR WORT[ -
OWNERSJ AE 'T t SEPT,CTANK,SEEP,PIT(3)
IG ADDREf ` AMD/OR DRAlXF1ELD
I HEREBY AC-KMOWLEDGE THAT I HAVE READ T 1$ APPLICATION CESSPOOL ElDRYWELL ElAND STATE THAT THE ABOVE 18 CORRECT AMD AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE$ AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OG '
PLUMBING AMD SEWERS. SEWAGE DISPOSAL By"$TE[
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED MD/OR DISCONNECT PLUG AND
LICEM9ED AS REQUIRED BY LOS ANGELES COUM Y D STATE OF
ALIFQRNIA O T I Y THE GAL OWN OF DO ABANDON HOUSE SETTER
E$CRIB D R THAOPERTY f BACKFILL$EPIC TANKS❑ / i7
1 8 PIT(8) CESSPOOLS
YI
JOHN A. LAMB-IE. CouNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBa. INSPECTOR'
OL M.0.
LAC;,)5 4 2 l n FEB 21 4 4.50 rn