HomeMy Public PortalAbout9049 GARIBALDI AVE_Sewer__ DEPAR'TAIIENT OF COU'N= ENGINFZB SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGr.T S
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
F R APPLICANT FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITYDISTRICT NO. I Ready for Inspection I PERMIT NO.
Z p C
NEAREST '--- 3�0 3 ! J
CROSS ST.
RECEIVED BY DATE I ,ISSUED BY DATE
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY BK MAP PO
CITY TEL.
CONTRACTOR V CO.IMP.NO.
ADDRESS JOB.NO.
CITY L.NO. TRUNK PERMIT NO. `
T
REGISTRA ON N0, ;2 E2 d COUSTANTEY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.OF BLDGS.
NOW 0 LOT CHARGES
USE OF
�1� /
BUILDINGS � _ ���� CONNECTION CHARGE FEE
NO. DES RIPTION OF WORK FE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO }
— PUBLICSEWER @ $ 8.50 G/ RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR �} EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 NO. I DATE BY
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
uprrw
LOWER
TYPE OF CONNECTION LENGTH FROM
; I _Y. CURB --41.46 M.L.TO P.L.
PERMIT
OWNERS _
AUTHORIZATION I TOTAL FEE O
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TOT IS PUBLIC SEWE
SIGNED THIS_ Y•DA OF .— S{a NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT. BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
ADDRESS------- ....._.._..__:_;:__........._............ AND/OR DRAINFIELD
I HEREBY ACKNOWLE GE THAT 1 HAVE RE I THISNAPPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AD AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OJ3 THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE D SCRI RESIDEN IAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(8�6_CESSPOOLS E] `
SIGNATURE
OF PERMIT
I
76A642D S&E 663 4/54