HomeMy Public PortalAbout9235 GARIBALDI AVE_Sewer__ c
TOeuD APPLICATION FOR PERMIT
T$A
COUNTY of LOS ANGELES SEWER—SEWAGE DISPOSAL
DIB?hHTbCWT TMENT OF COUNTY EIQGINEEH
B=ING AND SAFETY DIVISION ■UILDI Ho /R
JOHN A. LA30M
Sup.-S] Hy�++ LOCAL TI'
H EA R EST
FOE APPLICANT TO FILL IN10) 9 +� C'.. ST.
DESCRIPTION LOT HO. /�� �7 OWNER
MAIL
■LOCK TRACTS A I A- A N1 7-kADD
k -
DDR[1S
HO_ OF BLpGS.
SIZE OF LOT NOW OH LOT CITY TEL. NO.
USE OF 1
BUILDINGS EYED Ql'
■K ro /'►/
CONTRACTOR •���+���
ADDft[w Lj I CONNECTION DATA
CITY TEL. NQ. p �#4e4p STATION } .� DEPTH
REGISTRATION NO. a COUNTY MANHOLE R[FER[NC[ l
/ LOWER ti
NO. DESCRIPTIO OF WORK F[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWl:R CONNECTING TO Y. CUR■ P.L M.L.TO P.L.
PUBLIC SEWER $8.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.N -108 HO. 1
,ITS AHD/OR DRAINFI¢D $10.00
HOUR[SAW"CONNECTING TO N)( a COAD P[11Y fT NO.
PRIVATE DISPOSAL SYSTEM $7.00
COHN ECT ADDITIONAL■ .OR A IDAV IT EAng- [ASKKr RECORD.INSTR.NO. DATE
WORK TO HOUSE BEWER $7.00
OVERFLOW SEEPAGE FIT.DRAINFIELD
[XTTI..0 FOO L.DRYWLL L,MA NH OL[O $5.00
ALTER. AIR O ABA O HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMQ(T
FERMI T NO.
INDUSTRIAL
WASTE AFPROVA
OWNEH'3 P£BMT s z 00 CHARGES
AUMQE LATION I TOTAL nm CONNt H CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
REIMBURSEMENT FEE
TRACTOft TO CONNECT THE ABOVE DESCRIBED LXIQTING DWELLING
TO THC PUBLIC SEWER. APPROVALS DAT[ INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 10_ r
OWNER CR /[/) NEW HOUSE SEWER -
QWH[Rl AG[!LT / / ,� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HERESY ACKNOWLEDGE THAT I HAV[ READ THIS APPLICATION SXPTIC TANK,SEEP,PIT(S) i
AND STATE THAT THE ABOVE I■ CO RR[CT AHD ACRE[ TO COMPLiY AND/OR DRAINFI[LD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMB IN
AND •EWERR. CESSPOOL ❑ DnYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY RIGISTERED AHD/OR ALTER,REPAIR,BEWER OR
LICENSED AS REQUIRED BY LOS AHOLD E
COUNTY AND STATE OF SWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IH, THE ABOVE IDES Rif IDENTIAL PROPKim. ABANDON HOUSE SEWER
SIGNATURE SACKFILL SXrpC TANKS ElOF FMR YITTQ SEEP,lIT(S) IJ CESSPOOLS
VALMATIOP ROBERT A. WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
3774w 1TR2410 D 5.0 05: