HomeMy Public PortalAbout8713 GARIBALDI AVE_Sewer__ BA84'lo-0a
7 eAeaxD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DtPAETMENT OF COUNTY ENGWEEB
BUILDING AND SAFETY DIVISION ■UILDINO
JOHN A. Loom Com Ea ADO RSS
US
WILL .M IL JENSEN, Bap'f of 3 nr"-
LOCALI
NEAREST
FOR APPLICANT TO FILL INLZOAL
`"°" "
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. O LDGB.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PRBC ED SY
■UILDINOS SK PG
CONTRACTOR
-� - 1 6 r
ADDRESS .+J ` CONNECTION DATA
CITY TEL. NO. / 7 3 v STATION ` DEPTH O
ATI UPPER
REGISTRATION NO. O Z— COUNTY MANHOLE R[F[lR[NC[ LOWER
No. DESCRIPTION OF WORK FEE NN LENGTH
HOUSE SEWER CONNIECTIIIO TO Y. U P.L
PUBLIC SEWER 0 015.00 P.C.NO.
■ PTIC NK,■ AGE P OR CO. IMP.NO. 736 JOS NO.
PITS AHD/OR DRAINFI[LD 510.00
Ho■E■FW[R CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM 54.00
CONNECT ADD TIOMAL 3LQG.OR AFF4DAVIT • 11 [TENET RECORD.INSTR.Nd. DATE O
WORK TO HOUSE SEWER S2.00
OVERFLOW S[[PAG[PIT,DRAINFI[LD
E)CT N.,C[16POOL,DRYW[L L,YANHOLI 41 58.00
R.R PA ORA DO U■ HWY.OR ST.WIDKNINO
SEWER OR DISPOSAL SYSTEM 1.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
OWNER'S PEUCT ; x 00
CONNECTION-CHARGE FEE CHA ROU
ADTHOBMTION TOTAL FEE
'I HAVE AT THIS DAT[ A CONTRACT WITH TH[ HEREIN AMID CON- RFIMEURSEMLKT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIED EXISTING DWELLINO
TO THE PUBLIC BEWER. AMOVAIS DATE INSPE '■SIGNATURE
SIGNED THIS DAY OF 1D_
OWNER OR NEW HOUSE SEWER
OW N[IRS AGENT CONNECT A15DITIONAL
WILDING OR WORK -
ADDRISS SEPTIC TANK,SEEP,PIT(a)
1 HERtEY ACKNOWLEDGAD
E THAT 1 HAVE RETHS■ APPLICATION AND/OR DftAINFIELD
AND •TAT[ THAT THE AEOVE 1■ CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
FLUMEING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIRI D W LOS ANGLKB COUNTY AND STAT[ OF SEW/IGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND IKTTND TO DISCONNECT PLUG AND
REDID[ IN, THE ASOVE DESCRIBED RES DENTIAL PROPERTY. ABANDON HOUSE BI WER
SIGNATURE r
OF PERMS EAL`KFI T •v7�_C TANKS ❑
eEE�.PIT(■) L1 CEtsrooLE
VAMATIO ROBERT A. WOOD
8U-PERVISING MECHANICAL ENGINKER
CK. Y.O. CASH
ISO 9 S 1 6`�8 FEB 9 1 0 A 7.0 0-