HomeMy Public PortalAbout6438 GOLDEN WEST AVE_Sewer__ I °
S E-689 11.33
APPLICATION FOR PERMIT 1
3&E•6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
` Department of County Engineer
County of LOS Angeles BUILDI SGADDRE
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY +
FOR APPLIC NEAREST. t ni
0 L 0. / y 6 OWNER
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NO BLDGS.
NOW ON LOT CITY TEL. NO. �.
USE
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LDINGS DISTRICT NO. GROUP MAP
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CONTRACTOR ..v { _
ADDRESS
1'td CONNECTION DATA
may- STATION D:���LOWER
CITY / _ e �, TEL. NO����2 MANHOLE REFERENCE !�
iiiFFF STATE /G
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
i HOUSE SEWER CONNECTING TO - TYPE OF C„0rjBfCTION - LENGTH FROM
-a�J- @ $3.50 S(„/ Y. (C�QRBI P.L. M.L.TO P.L. � s
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.�j�
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 _PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING s
TO THE PUBLIC S'EWt;$,. NEW HOUSE SEWER +
SIGNED THIS AY OF JA.D A4 CONNECT ADDITIONAL
OWNER OR �� _BUILDING OR WORK
OWNERS AGENT vr/� SEPTIC TANK,SEEP, PIT(S)
ADDRESS _AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE 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 LAW'S REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTE AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES UNTY D STATE OF ABANDON HOUSESEWER
CALIFORNIA OR THAT I AM THE LEG 0 N OF THE ABOVE
DESCRIBED RESIDENTIALP ERTY. BACKFILL SEPTIC TANKS _ _
SIGNATURE _ SEEP._PIT(S) ❑ CESSPOOLS
OF PERMITTEE '
JOHN A. LAMBIE, CowwY ENGINEER ID ION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
�A O G 4 3 0 JAN 16 4 A 450 P