HomeMy Public PortalAbout9231 GARIBALDI AVE_Sewer__ ai��a I:.D+{f APPLICATION.:FOR PERMIT 1
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DIMON OF BUILDING AND SAFETY SEWER-SEWAGE D I S POSA L
D.partm.m of C--ty
Com of Loos An NUILDING /
MML J. FOX, CouNw ENGLNmxg ADDRESS /
CASSATT D.GRIFFIN.Surror,■UILDINs LOCALiTT
FOR APPLICANT TO FILL IN REARM
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LEGAL
DESCRIrTIOR LOT NO OWNER
BLOC[ TRACT NAIL
ADDRESS
NO. OF BLDGS.
SIZE OF LOT - NOW ON LOT CITY TEL. NO.
USE Or
BUILDINGS DUTR1�. GROUPI YAP
1![ PG
CONTRACTOR
ADDRESS „ CONNE4'lIOH DATA
CITY Q, STATION DEPTH
❑ STATZ MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY UPPER LOWER
10 S2
TYPE OF CONNECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y CURB P L Y.L.TO P.L.
HOUSE SEWER CONNECTING TO 29
PUBLIC SEWER $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP.X0. JOS. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMEIIT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR t�
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
t CESSPOOL-DRYW ELL
WASTE APPROVAL
SPECIAL CONbITIONS ONLY - 2.00 CHARGES
CONNECTION CHARGE FEZ
OWNEwS PMIET $ 1 00
AUTHOBMTION TOTAL FM REIMBURSEMENT Eg _
I R.AVE.THIS DATE-CONTRACTED WITH THE HEREIN NAMED COX-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINQ DWELLING APPBOVAIS DATt INSPECTOR'S SIGNATURE
TO TFIH PUBLIC 3 CA _
SIGNED THI AY OF I9 n[Ic HOUSE SEVER
OWNER OR CONNECT ADDITIONAL
OWNERS BUILDING OR WORK
SEPTIC TM K,SHED,PIT(S)
ADDR AND/OR DRAIXPIELD
I HEREBY ACKNOWLEDGE THAT I HAVE ION READ THIS APPLI T6x"POOL❑ DRYWELL❑
MD STATE THAT THEABOVE IS CORRECT MD AGREK TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATZ LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS. SEWAGZ DUSPOl;A.L SYST[N
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED ARD/OR
LICENSED AS RE"IRED BY LOS ANGELEY COUNTY MD STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL O*M9& Or THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RCSIDRNTL+LL rROPXRTY. BAC1Cr1LL C TAXES[]
SIIr rrT S c[:srO Ls
SIGNATURE
OF-PERMITTEE '� p
N�gLLIAM J.FOX, CouNw 1TNGiNum VAL=TPN
BY - . lBO 6 :rY9 2 UU-1 AUG , 4 2.0 0
DEPUTY DEPUTY
BY SY
m DEPUTY DEPUTY
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