HomeMy Public PortalAbout6448 GOLDEN WEST AVE_Sewer__ I �
CE808 2/70 ,APPLICATI FOR P MIT
76A 6420 y
COUNTY OF LOS ANGELES SEWER—SE GE PISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FLOCA
No
JOHN A. LAMBIE, COUNTY ENQI-NE[R
COLEMAN W. JENKINS. SUPT. or BUILDING (TY f;f 00 JP
NEAR
APPLICANT TO ILL IN CROSS BT.
(PRINY OR TYP-E ONLY) M,�
F.U,LD,...
CRIPTION LOT NO. OWIIER t
` MAIL --•
CK TRACT ADORW �!�(
OF ■LBO•.
OF LOT W 1' LOT Cfl"1' . TEL NO.
OF - DISTRICT R0. • OUP C AS MARm;�
BY
/� //yf� 6K PE
GOMTRACTOR V R S C `-J •O� Z 14~- 7
ADORV" //yy COH2[ECTio DATA
CITY TEL NO, �"y STATION DEPTH
STATE ICO [MANHOLE RffPKR[MC ?I S1FFR
LICE 29 NO GLASS A �J[J�
NO. DESCRIPTION OR WORK FEE TYPE OF CON ION LENGTH"60-1 aj �.....
OUSE■EWER gONN[CTING TO 100Y. P.L M.L.TO P.L. 027
►U■LI • E
Ew ER it 55.00
• IC TANK.SEEPAGE PIT OR �_ P n NO
PIT/AND/OR DRAINFIlLD � lIO.00
CO.IMP.NO. � JOS Nd.
HOUSE/EWER CONNECTING TO -rhuNK PERMIT NO. ROAD PERMIT Nd.
PRIVATE DISPOSAL SYSTEM 53.00 51/10
CONNECT ADDITIONAL■LDO.OR AFFIDAVIT WUnn I-E"" )T RECORD,INBTR.NO. DAT[ O
WORK TO HOUSE/EWER 59.00 CJ
OVERFLOW S[EPAO[PIT.DRAINFIELD
EkTN..CESSPOOL DRYW[LL M A NH OLE $11.00
ALT R.ROR DI/PO A R R ARA DO OU y HWY.OR ST.WIDENING O
•EWER SAL BY
M 7.00 {TATE ENCROACHMENT
PIRMITNO. YLLLLJJJ
CL
INDUSTRIAL (n
WASTE APPROVAL z
CHARGES
�7
OVINNEES"�$} PERJUT ; Oo
CONNECTION CHARD[F[E
AUTHOR=TION I TOTAL FEF` O
1 MAV[ AT THISDATE A CONTRACT WITH THE HrREIN NAMED CON- REIMSURS[MENT FEE
TRACtOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING OVAIS
TO THE PUBLIC SEWER. DAT[ INSPECTO R'f SIGNATURE
SIGNED THIS DAY OP
OWNER OR NEW HOUSE SEWER
OWNERSAO[NT
CONNECT ADDITIONAL
'Y 19UILDING OR WORK
ADDRESS •[ELIC TANK,■[EP,PIT(a)
I HERESY ACKNOWLEDQE THAT I "AVE RK" THIS APPLICATION AND/OR DRAINFI*LD
AND RTATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL COUNY ORDINANCES AND STATE LAWS REGULATING
FLU-M IND AIID STEW[RS. CESSPOOL ❑ DRYWELjr ❑
1HEREBY CERt WY THAT 1 AM PROPERLY REGISTERED AND/OR E
ALTER,REPAIR.■ WER OR
L10EMBED AS REQUIRED BY LO■ ANGLES COUNTY AND STAT[ OF SKWADS DISPOiAL SYSY[M
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBE tSIbENTIAL PROPERTY.
A RAN DON HOU Sit
•[W!R
SIGNATURE BACKFIL
OF PERMUTES CESSPOOLS S
mom
JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
C voA�LM�. cuH
1
0 5 51P MAY 7 1 0 1) 0.0 0 e 3