HomeMy Public PortalAbout8714 GARIBALDI AVE_Sewer__ 10-6276AS41D APPLICATION FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
w�xA. LMUL�, city �1__ ADDR[1i ;P"RC—jC_X5"DBY A Imo, Sn Oe Sym LocAurYNKAREST
FOR APPLICANT TO M IN CROSS ST.
LlaAL DESCRIPTION LOT NO owNERBLOCK TRACT ��Q,# MAILADDRESSNo. of eLDGDB= OF LOT NOW ON LOT CITY . NO.
UB[ OF �v�Cd .��� SDISTRICT NO. ORO YAP
■UILDINGS Q/JY
■K PO
CONT RACTOR �+� J
ADDR[fl /'43d 4gF.l-.4:::�yC dnoyA-`- go
NI?ECTION DATA S
CITYf TEL `NO-4 TA-� `S_ STAT D[J•TFi v/
REGISTRATION NO. i a0 STATE MANHOLE REFERENCE / JJ��
COUNTY
No. DESCRIPTION OF WORK FIE P[OF CONNECTION LENGTHY
/ HOU E BL1V[]1 CONNEGTINQ TO Y. CURL P.L Y.L.TO P.
PUBLIC SEWER 56.00Q P.C.NO. V
S IC ANK.SEEPAGE PTT OR JOB NO.
PITS AN
DRAINFIILD 810.00 GO.IMP.NO. ^�
HOUpE SEWBR CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 51.00
CONN[ ADDITIONAL■ .OR AFFIDAVIT EAIt[■ [AI[B[7T RECORD.INSTR.NO. DATE
WORK TO HOUSE SKIVER t $1.00
OVERFLOW SQR
PAO[PIT.DAINFI[LD Vl
E](TN.,CESSPOOL.DRYWELL,MANHOLE O 5B.00
ALTER,REPAIR NDOR O HWY.OR R.WIDENING
■EWER Oft DISPOSAL SYSTEM 1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
OWNE3rS PERMIT s z o0 CHARD is
AUTHORIZATION TOTAL FEF 10, CONNECTION CHARGE FII /r l
1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN MED CON- RELY DU RSSM[NT FEE gI W I V 1 I D
TRACTOR TO CONNECT THE ABOVE DESCRIBED LXI$TINO DWILLINO
TO THE PUBLIC BIWER, APPROVALS q DATE INEPBCTOR'/SIGNATURE
SIGNED THIS �DAAY OF lO_
OWNER OR �/I� !� NEW HOUSE SElYIR
OWNERS AGENT //L- Y CONNECT ADDITIONAL
■UILDING OR WORK
ADDRLS SEPTIC TANK,■ELP,PIT(S)
I HERESY ACKNOWL"K THAT I HAVE READ THIS APPLICATION AHD/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING CESSPOOL El DRYW[LL ❑
PLUMBERS
ING AND SWE .
IHrR"Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEINER OR
LICENS
CD AS R[OUIRED by
LOS ANGLES COUNTY AND STAT[ OF SSWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I ,AM THk LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE UF, THE X
[SCRI:�L),KK_rIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTJ_C TANKS ❑
OF PERM TTT[I SEEP,PITS) LI C[S/POOIJ
g7ATIONROB ERT A. WOOD
. CASH 5UPURVISING MECHANICAL ENGINEER
� 2 6 9 5 G NOV 19 1 0 A 7.0 0- 4