HomeMy Public PortalAbout6403 GOLDEN WEST AVE_Sewer__ D
S&E-663 11.55 APPLICATION FOR PERMIT _1
S 8:E-8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS sr.
LEGAL OWNER
DESCRIPTION LOT N0.
BLOCK TRACT oy
MAILADDRESS
N0.OF BLDGS./2 CITY TEL. NQ?�
SIZE OF LOT NOW ON LOT L�
USE OF DISTRICT t�Q. GROUP MAP
BUILDINGS �"
PG
CONTRACTOR � �� , ryC
S'6
ADDRESS � .c�" i , R r q e-,`�` — CONNECTION DATA
CITY •"1Q�,. ( TEL. N0. �4 / _ STATION t DEPTH
MANHOLE REFERENCE
4@--STATE -eej, LOWER
REGISTRATION NO. r 7 J ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIgN"""1� a
LENGTH FROM ' /
y� Y. CURB / P.L. 1 M.L. TO P.L.
F3
PUBLIC SEWER @ $3.50 ,7 —
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD `1 P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. N0, dP� JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK P RMIT N0. ROAD PERMI 0.
CONNECT ADDITIONAL BLDG.OR STATE ENCR HMENT
WORK TO HOUSE SEWER @ $1.00 �� PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARG EE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE L+.- REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER a -
SIGNED THIS F 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS - AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL[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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY. LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL. ROPERTY. % * BACKFILL SEPTIC TANKS
T ❑
SIGNATURE SEEP.PIS) ❑ CESSPOOLS "1 1
OF PERMITTEIf_1 '" - / '
III JOHN A. LAMBIE. UNTY ENGINEER' VALIDATION ROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK. M.O. CASH
., 0 6 6 9- SEP 2 6 4 5.50 In