HomeMy Public PortalAbout6355 GOLDEN WEST AVE_Sewer__ 7GA"XM FOR PERMIT
`'�DrvImON OF BUILDING AND SAFETY SEWER—SEWAGE D 1 S POSA L
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LDING
WM.J. FOX, COUNTY �Na1N[[R DRESsC.A*"TT D. GRIFFIN,"'T OR SUMMIXO CALITYFOB APPLICANT TO FILLINCROSS --�
LEGAL �d
DHSCQIPTION LOT MO, 07XBSt
BLOCK TRACT JOS, MAIL
ADDRQ"
N0.OF BLDGS.
SIZE OF LOT XOY/ON LOT CITY. TEL. N0.
USE OF
BUILDINGS DIBTRI , GROUPI MAP
CONTRACTORxvl� 05
pG
ADDRESS CONIU=ON DATA
CITY TEL. MQ-e�ozlSTATION / DEPTH r
STATL MANHOLE REFERYMV
REGISTRATION NO. ❑ COUNTY —54,
Z LOWER
TYPE ECTION LENGTH FROM
No. DESCRIPTION OF WORK FFE Y. CUR P.L. Y.L.TO P.L.
IC SEEWEER �nXECTING O
( 3.110
HOUSE 56VER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM 1.00
CON CT ADDITIONAL BLDG. OR Co, IMP. N0. �. JOB. NO.
WORK TO HOUSE SEWLR __1_.00_
ALTER OR REPAIR E( STING
SEWER OR ISPOSAL SYSTEM 1.00 TAUMR PERMIT X0, ROAD PLRMIT NO.
DISCONNECT AND ABANDON SEWER EHCROACHY
AMD/OR DISPOSAL SYSTEM 1.00 STATE STATENO.
SEPTIC TANK,SEEPAGE PIT OR P _IT
PITS AND/OR DRAINFIELD 1.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 1.00 C tG►`S
O CONNECTION CHARGE
PEMET s I o0
AUTI30flZZXTION TOTAL FEE R IMBURIEYG fi
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED COM-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGLI G APPHOtr•ALS DATE INSPECTOR'S B1 NATURL
TO THE PUBLIC f Kit
SIGNED THI AY O972t9i& 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSG N BUILDING OR WORK
SE C TANK, SEEP PIT(G)
ADDREE AND OR DRAINFIELb
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CEBSNOL[IDRY*ELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ND STATE OF ISCONN HOUSE SEWER
AND
CALIF gRX1A OR THAT 1 AY THE LEGAL OINX OF THE ABOVE
DESCR QED RpIDENTIAL P OPERTY. BACKFILLf CTA ,O❑
PEEP.PITS C1�8POOLi
SIGNATURE
OF PERM[
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n6 9 9� MH13 4 4.50 m
MY
DEPUTY DEPUTY
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