HomeMy Public PortalAbout8613 GARIBALDI AVE_Sewer__ C[SOS 5L85
75A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
D2PARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ■U ILDINo
JOHN A.LAMBIE, County En$Imeer ADDR[as
COLEMAN W. JENLINS,Sop t. of Baildlms
L OCA L TTY
NEAREST
FOR,APPLICANT TO FILL IN C'.'/ '.
DK KFt lot<TI ON LOT NO. dk/4OW N[R
MAIL
■LOCK TRACT ADOR ESD
NO. OF SLOGS.
■IY[ OF LOT NOW ON LOT CIT' TEL NO.
USE OFDI/TRI CT NO. GROUP MAP PROC El6[I}SY
AUILDINGa SK
(a/J- ///�/�p�
CONTRACTOR it Fi 6
ADDRESS CONNECTION DATA Vim/
GIT TEL. NO. O STATION ! DEFTH
LICENSELICE N5E J
NO. O CLJ11. �� 2 MANHOLE REFERENCE
No. DESCRIPTION OF WORK FEE TYPE OF ION LW FRoM
OUSE SEWER CONNECTING TO Y.1 C F.L. M.L.TO P.L.P USLIC.SEWER / $ 5.00 t
P.C-No.
PITS AND/OR DRAINFIELD / $10.00 CO.IMF. NO. JO■NO. (�
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ;VG
PRIVATE DISPOSAL SYSTEM f $ 9.00 ROAD PERMIT NO.
OL
CONNECT NAL KLD6. OR AFFIDAVIT FAII[S[rt RECORD.IN•TR.NO. DATE O
E
WORK TO HOUSE SWER / $ 9.00ALTLK, REPAIR OR NOON HOUSE
`
SEWER OR DISPOSAL SYSTEM 0 $ 9.0.0 {LLVJ,
HWY. OR ST.WIDENING d
to
EAT M.,CESSPOOL. NAlIHOLE 0 $
6.00 STATE ENCROACHMENT Z
PERCOLATION TEST S S 5.00 PERMIT NO.
INDUSTRIAL
WAIT[APPROVAL
CHARGES
OWNERS s z 00
AUTHORIZATION I TOTAL. FEE p CONNECTION CHARD[FE[
'I HAVS AT THISDAT[ A CONTRACTT [
WITM HE HR[IN NAMED CON- REIM■URS[M[NT FEE _
TRACTOR TO CONNECT THE ABOVE D[SCRIB[D EXISTING DWOLLING
TO THE PUSLIC ■ ER APPROVALS DAT[ INSP'ECTOR'S SIGNATURE
SIGNED TNI" AY OF 18 d
OWNER OR NEW HODS[/LINER
OWNERS AG[ CO NN[CT ADDrTION AL
ADORES■ 9411-7 A
■U I LDING OR WORK 1
/[DTIC TANK.SEEP,PIT(S)
1 H[R[SY ACKNOW L[DG[ THAT I HAVE ROAD THIS A!'!"LIGTION AND/OR DRAINFI[LD
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
LLU AND Sew ERs. CESSPOOL ❑ DRYW[LL ❑
ESY CIENTIFY THAT I AM PROPERLY R[OISTERID AND/OR ALTER,REPAIR,6[W[R OR
D AS R[OUIR[D ■Y LOS ANGLES COUNTYAND STATE OF SEWAGE DISPOSAL SYSTEM
NIA OR THAT IAMTH[ LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
IN, THE ASO CRIBED RESIDENTIAL F OP[RTY. ASANDON HOU■E SI W[RR[ CBACKFILL.FDNC TANKS ❑ JJ�RMITTEE a[Er.PR(S) L� CWPOOL/ TGr �'\
VALIDATION
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