HomeMy Public PortalAbout6413 GOLDEN WEST AVE_Sewer__ 76A642D APPLICATION FOR PERMIT _ 1
8&E.663 3•SS
DIVISION`OF BUILDING AND SAFETY SEWER—SEWAGE D I S POSA L
Deportment of County Engineer
County of Loa Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST. 'r�0
LEGAL r
DESCRIPTION LOT NO..t 4,V X4 li t • OWNER
i
BLOCK TRACT MAIL
ADDRESS
NO. OF BLDGS. / [ �—
SIZE OF LOT NOW ON LOT ✓ CITY TEL. NO. OL 7
USE OF
BUILDINGS DISTRICT
NO. ( GROUP BK MAP
PG
CONTRACTOR L
i
ADDRESS -2-L CONNECTION DATA
CITY OkA 1-1 a ,,I C TEL. NO. f'-V �/� STATION f D 3,_$_'DEPTH pIf'a
ia-STATE MANHOLE REFERENCEi'r� UPPER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
.4 CURB P.L. M.L. TO P.L. it
_PUBLIC SEWER @ $ 3.50 S 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. NO. JOB NO.
ALTER TRUNK PERMIT NO. ROAD PERMIT N0./O
I
EWER_OR
OREPAIR EXISTING
R DISPOSAL SYSTEM 1.00
1 DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
1 - AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
1 SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD -3.00 INDUSTRIAL
CESSPOOL-DRYW ELL
WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
1 00
OWNER'S
PERMIT CONNECTION CHARGE FEE
s
AUTHORIZATION I TOTAL FEE 41 7 o REIMBURSEMENT FEE p
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS DAY OF 19-
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS - -^'F!' AND/OR DRAINFIELD
IO ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[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
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 Ap THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PjCOPERTY. BACKFILL SEPTIC TANKS
// SEEP.PIT(S) ❑ CESSPOOLS❑
SIGNATURE �l
OF PERM ITTE-
WILLIAM J.FOX.CO NTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLEG. INSPECTOR
1