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COUNTY OF LOS ANGM- SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY EIfQ,XEEB
BUMDOG AND SAFETY DIVISION SUILDIMG
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T°AG-420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELS
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTT ENGII=
BUILDING AND SAFETY DIVI$IQN BUILDING
EV ADDRISS, 9233 Garibaldi Ave,
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LPaul Meeker
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BLOCK TIAtT ADDp� 92 35 Garibaldi Ave.
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1 HAYI AT THIS DATE A CONTRACT
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OWNER OR CIANIA
OWNERS AGEIIT BUILDING 0"0'
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I HPIBT ACKMOWLXPS11 THAT K HATE PUMP THIS CATIOX
ANP STATE THAT THE AbM IS AND AGAU TO CANFLT CnSPDOL DRTWKL
WIT ALL COUNT; 0 IXMCib A aD ETATE LAWS RIQULATINQ ALTTIip,R,,REPAIR.SEWER OR
ILI BIRO AND SEWAGE DISPOSAL EYST8
1 HPHBT rMMFT THAT I AN FIOFKRLT RYGIETIIID AND/ON DISCONNECT FLUS AND
LICENSED AS REQUIRED ST LOS MGEPD C90MTT MD IFTATI OF ADAXDON HOUSE SEMEN
%CC�AILIFORNIA OR THAT 1 M THI LEWLL OF TU ABOVE ILL f C
CF4IBED RAW TAXKfFIT S
SIGNATURE
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°' APPLICATION F50R PERM T
COUNTY OF IAS ANGELES SEWER�SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUELDING AND SAFETY DIVISION ■DW JOHN L T Em Bir A
I-
WML1L TBMUN. Sup'f of undiaq
LOCALITY
NEA REST
FOR APPLICANT TO IN vx4 `R'i/ 'T.
DESC PTION LOT HO. OWNER
BLOCK TRACT T A /Err ITA MAIL ,
ADORE"
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL NO.
US[ DISTRICT NO. OROUP MAT PROdSASED tY
■UILDINOS
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CONTRACTOR �// D CK
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ADPREsb , � r CONNECTION DATA
CITY TEL. NO. Q lnp f� o P l STATION DEPTH
ST'A'TE MANHOLE REFERENCE
REGI TION NO. IxCOUNTY L
No. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEI'IGTH FROM .
HOUSE SEWER CONNECTINO TO Y. CURE P.L M.L.TO P.L
PUBLICAWWER 55.00 P.C.NO.
S IC AHK,■ O[PR OR JOB HO. .
FIT/AND�OR DRAINFIELD /10.00 CO.IMF.NO.
HOUSE SEWER CONNECTING TO
PRIVAS DISPOSAL SYSTEM 59.00 TRU P /O/ ij ROAD FmtM IT NO.
CONNECTBL,
ADDITIONAL DO.OR AFFIDAVTT IrMM [AliWi RECD-ORD.INSTR.NO. DAT[
WORK TO HOUSE/EWER 53.60 -�
OVERFLOW SEEFAOE FIT,DRAINFIELD
EXTN.,CESSPOOL..DRYW[LL,MANHOLE t $5.00
AL RIEPAIIR OR AEA O HWY.OR ST.WIDENING
S IIV[R OR DISPCISAL SYSTEM f3.00 STATE QiCROACHMXNtT
PERMIT NO.
I N DU STR IAL
/�
WMT[APPROVAL
O`_NEN S PERMrr s 2 00 CHARGES
CONNECTION CHARGE FEE
ALTTF30BTLATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE YEREIN NAMED CON-
T
RACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC /EWER. APPROVALS DATE INSPECTOR'•SIGNATURE
SIGNED TH18 DAY OF ID_
.OWNER OR NEW HOUSE SEWER
OWNERS AO[NT
v CO►W[GT ADDITIONAL _
ADDRESS BUILDING bR WORK
SND IC TANK,■ SKI PITS) - 6
I HEREBY THAT
THE A20 THAT I HAVE READ THIS APPLICATION AND/OR DRAINPI[LD -
AND STAT[ THAT TH[ ABOVE IS CORRECT AND AGREE TO Co
WfTH r.LL COUNTY ORDINANCES AND STATE LAWS REOULATINO CESSPOOL ❑ DRYW QL ❑
PLUMBING AND SEWERS.
1 HERESY 4ERTIFY THAI I AY PROPERLY REGISTERED AND/OR ALTER,REPAIR,/EWER Oh
LICENSED U REQUIRED ■Y LOIS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
U .EA
LFFORNIA OR THAT I AM THE LOAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
REBID[ IN, Ttl6 AE D URIStD RESIDENTIALPRO ABANDON HOUSE SEWER
SIGNATURE ElOF PERMfTTQ BACKFILL SEPT C TANKS
SEEP.PIT f/) CESSPOOLS_
Lp 1 VALM.0. � ROBERT A. WOOD
CK. Y.O.
y SUPERVISING MECHANICAL ENGINEER
-
CASH
u � 3 7 7 UR 24 1 0 D 5.c0 '