HomeMy Public PortalAbout6424 GOLDEN WEST AVE_Sewer__ DEPARTMENT OF COUNTY ENGINI= SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO LL IN LOCALITY
BUILDING 011 EAREST
ADDRESS CROSS ST.
LOCALITY `T DISTRICT N0. I Ready for Inspection I PERMIT NO. c
NEAREST
CROSS ST.
RECEIVED BY, DATE ISSUED BY DATE
OWNER
MAIL USE ZONE + OCCUPANCY -M"--
-ADDRESS BK PG
CITYr !' TEL.NO. ' ' ( 1 7
CONTRACTO /f
® ` CO.IMP.N0.
ADDRESS` JOB.NO.
CITY / TEL.NO.a 'jf�/ TRUNK PERMIT NO.
p�Q� TATE
REGISTRATION N0. O� COUNTY ROAD PERMIT N0.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. CHARGES
NOW ON LOT
BUILDINGS ,%/�j>oj��Q�/ CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
/ HOUSE SEWER CONNECTING TO
PUBLICSEWER ! $ 3.50 r RECEIPT NO. DATE � BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR TT EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 _� y
ALTER OR REPAIR EXISTING O• I DATE I BY
_
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION r DEPTH '
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER -LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 00 Y. -CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE l
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER -
->
A�
SIGNED THIS..�� ---DA OF _I NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AWT_ iJ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........ AND/OR DRAINFIELO
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE ESCRIB IDE IAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)E] CESSPOOLS
OF PERMITTE .i�+c' -- - ----.._.
76A642D S&E 663 4/54 C- �� /
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