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HomeMy Public PortalAbout8853 GARIBALDI AVE_Sewer__ r , CE84 APPLICATION FOR PER T 7QA842D COtRM OF IAS ANGEIM SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGMM BUrLDING AND SAFETY DIVISION BUILDING ADDRW v�°1hL'jM s 7' E $1MQ LOCALITY / NEAREST FOR APPLIC TO FILL IN CROSS DESCRIPTION LOT N OWNER MAIL BLOCK TRA qrT ADD NO. OF VCDOS. SIZE OF L NOW ON LOT C US[ OF t DI ICT NO. GROUP YAP PROCES SLD BY BUILD( ■K PG CONTRACTOR + V L e / ADDRESk / CO TION DATA STATION C)[PTH 7STAT[ MANHOLE R[FERENC[ REGISTRATION NO. .3 / • COUNTY NO. 1 DESCRIPTION OF WORK FEE IS OF CONNECTION LENGTH FROM HOUSE S[WE11 CONNIECTINO TOY. CURE P.L M.L TO P.L. PUBLIC BEWER a $15.00 P.C_NO. SEPTIC TANK.S P O[P CO.IMP. NO.OR 3 JOB NO. PIER To AND/OR DRAINFI[LD $10.00 __ AA HOUSE SEWCONNECTING TO TRUNK PERMIT NO. ROAD PEAlMIT N-W PRIVATE DISPOSAL SYSTEM $9.00 VVO CONNXCT ADDITIONAL BLDG.ON A (DAVIT I WAI"I I "A "SUIT RECORD.INSTR.NO. DATE WORKTO HOU;E SEWER $2.00 OVERFLOW SEEPAGE PIT,DRAINPIELD EXTN.,CESSPOOL.DRYW1n I MANHOLE 48 $8.00 LTER,RKPAIR O DO HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM 41 V3.00 STATE XNCROACHMENT PERMIT NO. INDUSTRIAL WAST[APPROVAL OW.NEkS PERMIT t 2 00 cHAROES AUTHORIZATION TOTAL FCONNECTION CHARGE FEE EE '1 HAVE AT THIS DATE A CONTRACT WITH THEH IN N MLD CON- RE EIMSURSEMENT FE TRACTOR TO COf4NECT THE A;OVE DESCRIBED TO TH[ PU■LIC ■EWER. APPROVALS DATE INR sP ';SIGMA RE SIGNED THIS DA 10_ OWNER OR NEW HOU;[SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SPTIC TANK.SEEP.PITS) 1 HERE■Y ACKNOWLEDOE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STAT[ THAT TH[ ABOVE 1; CORRECT AND AO REE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUYSINO AND SEW[RS. CESSPOOL ❑ DRYWLLL ❑ I H[R CERTIFY THAT Y PROP[RLY REGISTERED AN /OR ALTER.REPAIR,SEWER OR LICI NS RE IR 1D ANGLES PTY AND A OF SEWAGE DIEPONAL■YBT[M CALIF A O LEGA O E OF D TO DISCONNECT PLUdI AND REST IN, ABOVE RI AL ASANDON HOUSE SEWER L K BACKFILL S[P�IC TANKS ❑ P IT(B) LJ CESEPOOu VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER K. Y. 0998 FO 15 :1 0 0 998Fps1510 © 7.00N �