HomeMy Public PortalAbout9112 GARIBALDI AVE_Sewer__ S&E•6-689 11.58 D
3 APPLICATION FOR PERMIT --- -5
@
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of LOS Angeles BUILDING -
ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYNEAREST -
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
Nd.OF BLDGS. CITY TEL. NO.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS _ I BK PG
CONTRACTOR -
CONNECTION DATA
ADDRESS -
STATION DEPTH
CITY T400. MANHOLE REFERENCE U. P.ti3
❑ STATE LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
---PITS AND/OR DRAINFIELD @ $3.00
P. C. NO.
OVERFLOW SEEPAGE PIT.DRAINFIELD o
I
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP.N0. 2 JOB NO.
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
1 CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
_ SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ ";y 00 REIMBURSEMENT FEE fficlV�7109 aZ �'YJAL
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR _BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
--
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS El '
DESCRIBED RESIDENTIAL PROPERTY.
SEEP.PIT(S) ❑ CESSPOOLS❑
SIGNATURE �~
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD.CHIEF PLBG. INSPECTOR
CK. Y.O. CASH