HomeMy Public PortalAbout9160 GARIBALDI AVE_Sewer__ 7ieCe4tD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEERSEWER—�WAGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDING
ADDRiIf
JOEEK JL Tfl/RTF_ Cotmty En far
WILLIAJA A. TDOUN, Sup'4 of ftnrMng G
LOCALITY rlj
FOR APPLICANT TO FILL IN
LEGAL
_)"C RIPTION LOT NO. ! OWNER
QMAIL
BLOCK TRACT / ADORES
NO. OF BLDd/.
SIZE OF LOT -t� NOW ON LOT CIT' TEL. NO.
US[ OF DISTRICT NO. GROUP' MAP' PROCCSSED By
BUILDINGS
■K PG
R
CONTACTOR
l _I'=- 6 �1 1
ADDRXSS CONNECTION DATA
/ [2_ S STATION 1--3v Z - DEPTH
C I TIL N Y
REG'1STRATION NO. , CTA E MANHOLER.FlRENC[ /DSS_ LowER
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM `
HOUR[SEWER CONNECTING TO n ^ Y. CURIO P.
M.L TO P.L
PUBLIC IEWER •8.00 go P'.C.Np.
S IC TANK,■ AGE PIT OR /Z JOB NO.
PITS AND/bR DRAINFI[La SI0.00 CO.IMP'.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Q(
E
PRIVATDISPOSAL SYSTEM Q Sa.C0 0
CONNECT ADDITIONAL■ G. AFFIDAVIT 7Aftu [Aiv[l'f R[GORD.INSTR.NO. DATE
WORK TO HOUSE■EWER 0 $3.0.0OVERFLOW SEEPAGE FIT.DRAINFIELD
EXTN.,CESSPOOL,DRYWELLMANHOLE 6 •5.00 d
h
REPAIR R A O HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 0 Sa.00 STAT[ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAIT[APPROVAL
CHA RG[S
OWNM'S PMUCT c�r� s : o0
AUTHOTUZATION TOTAL FEE CONNECTION CNA RG[FEE:
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM. REIMBURSEMENT FE[
TRACTOR TO CONNECT THE ABOVE D[SCRISKO NG
TO THE PUBLIC SEM/ER. APPROVALS T[ INSPECTOR'S SIGMA
SIGNED THIS _DA1Y^^OF 10_
OWNER OR 4� NEW HODS[SEW E1
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(4)
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/bR DRAI Nor
I[LD
AND STAT[ THAT THE ASOVE 19 CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW[". CES/FOOL El DRYWELL El
1 EB
HREY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
D
LICENSED AS R19OUIREBY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
H
RESIDE IN, THE AB V� D[SCRIEED R IDENTIAL ►ROP[RTY. ABANDON HOUR[SEWER
SIGNATURE BACKFILLSKP`U TANKI ❑
OF PERMITTEE SEEP,RIT(a) u CEISPOOLS
VALIDATION ROSENT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER .
L&0264Z ,!mI9 1 o 0 ?SOON W