HomeMy Public PortalAbout9235 1/2 GARIBALDI AVE_Sewer__ 76EA64XD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGIN
BUILDING AND SAFETY DIVISION 7AD
Offif A T[1[RTF Fa K GfQFOR APPLICANT TO FILL IN
DESCRIPTION LOT NO �ffeV O OWNER
MAIL
BLOCK TRACT O AbOR[SSJ22,
NO. 00 e1,Doe. )per
SIZE OF LOT aQ NOW ON LOT /T
T<L NO
US[ OF
SU ILDINGS NO. GROUP MAF BY
( BK PG
CONTRACTOR -/
ADDRESS 'CONNECTION D TA
[Le07D[PTH
UPPERR[OISTRATION NO. R[F [ LOWS
No. DESCRIPTION OF WORK PIKE of coNN[cr n GTH FROM
HOU•[SEWER CONN[CT)NG TO CURB P.L. .L.TO P.L.
PUBLIC SEWER 55.00
rP.0 Nb.
DKPT ICDA • AO[FIT OR CO.IMF.NO. JOB NO.
PITC AND/OR DRAINFI[LD � 810.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ` 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I •Arr" [A[It Qf RECORD.INSTR.P47 DAT[
WORK TO HOUSE SEWER $3.00
I OVERFLOW■[EPAGE PIT.DRA4HFI[LD
[XTN.,CESSPOOL,DRYWELL,MANHOLE 0 $5.00
BA. DON HOILIdt HWY.OR ST.WIDXNIP40
SEWER •TSM 0 43.00- v STAT[ENCROACHMENT
h _ PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
CHARGp
� i7.lLOWNER'S PERMIT • x 00
A�7UliZOATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT TRIS DATE A CONTRACT WITH THE HBR[IN NAMED CON- R[IMSURS[M[NT FEE
TRACTOR TO CONNECT THE ABOVE D[SCRISSD LXIBTINQ DWELLINGO
TO THE PUBLIC SEWER. APPROVALS
DATE INSPLCTOR'■510HATURK
SIGNED THIS DAY OF 1Q_
OWNER OR NEW HOUSE SCW-M
OWNER•AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 H[R[BY ACKSEPTIC TANK.•Lp,PIT(■)
NOWLEDdL THAT I HAV[ READ THIS APPLICATION AND/OR DRAINFIELD
AND STAT[ THAT THE ABOVE If CORRECT AND AGREE TO COMPLY
WITH ALL COVNTY ORDINANCES AND STAT[ LAW Ri
[GUATING
PLUMBING AND SEW SRS. CESSPOQL ❑ ORYWELL ❑
I H[R[BY CERTIFY THAT IAM P
AROPEALY REGISTERED AND/OR ALTER.REPAIR,SEWER OR �
LICD ENSEAS R[QUIRID BY LO■ ANGLES COUNTY AND STATE OF SEWAGE DIBPOGAL SYSTEM /
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
REBID[ In, THE A19OVK 'RI BED RESIDENTIAL PROPERTY. DISCONNECT PLUG AND
A BAHDON H9US[SEWER
■I ONATUR[ BACKFILL S[P[NG TANKS ❑
VAMATI� ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH
L,. g 1 2 JAN21 1 0 0 5.Q 0