HomeMy Public PortalAbout9229 GARIBALDI AVE_Sewer__ APPLICATION - FOR PERMIT
i �MBION OF BITtMG AND SAFETY SEWER—SEW,UeAGE D I S POSA L
D.pazt,a.at od �tr End
COImt7 of jps BUILDIXR
WIW.J.FOX, COUNTY BHIfINNXR ADD
CASSATT D.GRIFFIN,Sup-T or■UILDINO 1.00ALIYY _
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCL L TRACT ■AIL
DDRES3
Xo.OF BLDaa. '
SIZE OF LOT N011 ON.LOT CITY No.
USE OF
! BUILDINGS
DISTf41CT NO. GROUP YAP
�.
BE PG
CONTRACTOR d5
ADDRESS .! �a,}�� _ i COMU=OH DATA
CITY j TEL , STATION DEPTH
❑ STATE MANHOLE REFERENCE
R4SGISTRATION N0. ' ❑ COURTS UPPER LOW ER
.— ,. TYPE OFCONNECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y CURB P L. Y.L.TO P.L.
HOUSE SEWH CONNECTING TO
PUBLIC SEWER' >♦ 3.30
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG, OR �y Co. IMF. No. JOB. NO.
WORK TO HOUSE SEWER 1.00
�1ER OR REPAIR G
EWP67TRUNK PERMIT NO. ROAD PERMIT NO.
EWER OR D19AL SYSTEM
EM 1.Q0 .
DISCONNECT AND ABANDON SHRIEK STATE EXCROACHYHNT
AWD/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAIXFIEID 2.00 IXOUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OVPIER'S »r spl oo
AUMOMATION TQT)�L FEB RE114BURSEMFKT FEE .
I I )SAVE THIS PATE CONTRACTED WITH THE HEREIN RAYED CON- ,y
TRACTOR TO CONNECT THE ABOVE DESCRIBED F.KIST1Mp pWEWNG APPROVALS DAT$ MSPECTOR•S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THI AY OF NEW HOUSE SEWER - 3_
OWNER ' OR CONNECT ADDITIONAL -
OWNERS AQ?2 BUILDING OR WORK
EPTIC TANK,.SEEP,PIT(S)
ADDR ND OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLIGTI N CESSPOOL❑ DEYWELL❑
i AND !TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AMD STATE LAWS REGULATIRG
PLUMBING AND SEWERS. ALTER, REPAIR SEWER OR
I HEREBT CERTIFY THAT I AM PROPERLT REGISTERED AN /OK SAGE DISPOSAL BYSTEiI
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATES OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF TAY ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPIRTI. BACKFILL 3" q TI
Q[EP PIT CESSPID0
SISNATURI
OF PERMITTEE
WII L reu.J. FOX,COUNTY rLisic isiml VALMA71ON
lry —Co 6 1 g 3 r, Atm 1 4 2 .00 10
DEPUTY DEPUTY
BY BY y
.�'m DEPUTY L DILPUTY