HomeMy Public PortalAbout6406 GOLDEN WEST AVE_Sewer__ APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D 1 S POSA L
Depaxtnent ofEngh~
G>mmit7 of I" Ang*lM BUIL
WM.J. FOX. COUNTY EEimimSODl ADDRESS
CAA"Itl.TT'R•GIFUMH, 8tn-T OR■UUMms LOCALITY
FOR APPLICANT TO FILL IN A
LEGAL
DEECRIPTIOX ATN10. OWNER
BLOCK TRAC� 2 MAIL
ADDRESS
0. OF BLD
S129 OF LOT O x /J_ 1 NAW ON LOT=S I CITY TEL. NO.
USE OF
HUI D 8 DISTRICT NO. GROUP YAP
B[ Pa
CONTRACTOR
ADDRESS COMUZnON DATA
CITY TEL. N0. STATION DEPTH
REGISTRATIO NO. / /� Alm
ATE MANHOLE REFERENCE
COUNTY LOWER
no. DESCRIPTION OF WORK FEY
HOUSE SEWER CONNECTING TOTYPE VECTION LENGTH FROM �
PUBLIC SEWER 3.30 Y' P.L Y.L. TO P.L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITiONAL BLDG. OR P. C. N0.
WORK TO HOUSE SEWER 1.00 CO. IMP. N0. jttg JOB N0.
ALTER OR REPAIR MS71MG
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC T/{NK, SEEPAGE PIT OR f11bUSTRIAL
PITS AND OR DRAINFIKLD .00 -
CESSPOOL-DRYWELLA-PPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES,
Omapmmff $ 1 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEEI HAVE DATE �fy11f„
COX-
TRACTORTTO CONNECT THE ADOYS DESCRIBED EXISTINGTRACTED WITH THE HEREINAMED DINELLINq APPROVALS DATE IMSPSCTOS'S819KATURE
TO THE PUBLIC SEWER /
SIGNED THI Y OF 19 KE HOUSE SERVER
OWNER XOR COMNECT ADDITIONAL
OWNA 22.91BUILDING OR WORK
ADDR
SEPTIC TANK,BEEP, PITH
AND/OR DRAINFIELD
I HERESY ACKNOWLEM THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTFR,REPAIR,SEWER OR
PLUMBING AND ITWIES. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DKSCEIBRD RESIDENTIAL PROPEYTY. BACKFILL SEPRC TAXIES❑ /
SEEP. PIT E CP9lPOOLB b
SI G11ATU RE
OF PERYITm
1fY11 r Feu J.FrOX.Courlrr rLNaLxxKR VALIDATION R.A.WOOD. CHIEF M_". INir[CTon
9864.N sEP .4 4 �#5�3 �