HomeMy Public PortalAbout9239 GARIBALDI AVE_Sewer__ 6A642-
7
D 62 APPLICATION FOR ERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building `
LOCALITY
NEAREST .
O P LIC TO FII.L IN
CROSS
ST.
LEGAL /
DESCRIPTION L O. OWNER
MAIL
BLOCK f TRACT _ ADDRESS
NO. OF SLOGS.
SI L NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS BK DISTRICT NO. GROUPJ MAP PROCESSED BY
PG
CONTRACTORZfF
ADDRESS ?/ CONNECTION ATA
CITY T
STATION t - DEPTH
L.
STATE
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE ` UPPER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM A}
OUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. n.
PUBLIC SEWER @ $5.00 O
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR V
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO O
TRU ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM � $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT w tVER EASEMENT DATE
WORK TO HOUSE SEWER - @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWEL L,MANHOLE @ $5.00 HWY.OR ST.WIDENING Z
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE
d CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY 19_ a
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL �'I
ADDRESS BUILDING OR WORK a _
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I M PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRE B OS ANGLES COUNTY AND,S ATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT E LEGAL OWNER OF, AND I END TO
RESIDE IN, THE AS 'RIBED RESIDENTIAL PROPE Y. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALMATI0V -1 ROBERT A. WOOD
CK. M.O. SUPERVISING MECHANICAL ENGINEER
CAS
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