HomeMy Public PortalAbout9243 GARIBALDI AVE_Sewer__ C
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TGA64Eo a62 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTT ENGINEEE
BUILDING AND SAFETY DIVISION Bu1LDI-G
OEIN A. SIE ADDRw
VVILLLPLU A. TENKIM, Sup'f of nmlatn4
LOCALITY
R[AREST
I
ANT TO FEU N CRO" ST.
DESCRIPTI"BOWLON LOT NO. frt l� OWNER
� MAIL
OLOCK TRACT ADbREEB
NO. Or ■LOGS.
SIZE OF LOT Na OH LOT CITY NO.
USE OF DISTRICT NO. GROUP P "OC[lQrD BY
BUILDINGS
/1 J■K ro
'CONTRACTOR
ADDRESS CONNECTION ArA
CITY TIL Hp. STATION 4' -7 D[FfH
iWTA- MANHOLE R[F"KP4C[ JJJJ ✓ UPP"
REGISTRATION NO. COUNTY / 3 ' -{pycM,r
No. DESCRIPTION OP ORK FEETl' oN-[ ON LENGTH FROM
-HOUSE SEWER CQHN[ I TO Y. M. TO P.L
PUBLIC•[W[R 0 X8.00
S FTIC TANK,6 O[FIT OR .C.HO.
FITS AND/OR DRAIHFIELD 0 510.00 CO.IMF•NO. JOB no.
HOUSE
SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT No.
PRIVATE DISPOSAL SYSTEM 0 [7.00
CONNECT ADDITIONAL BLDG. R AFFIDAVIT fAfY[l [1/DIR RECORD.INSTR.NO. DATI
WORKTO HOUSE SEWER 0 $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
E 7(T N.,CESSPOOL,DRYWELL..MAHHOLE 41 SB.00
ALT R,R AIR OR O HWY.OR ST.WID[11ING
SEWER OR DISPOSAL SYSTEM 1/31.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
owNEx's PEHMTf : z 00 CHARGES
AUTHORIZATION TOTAL FEE CON-[ N CHARGE FEE
I HAVE AT THI■ DATE A CONTRACT WITH THE HEREIN NAMED CON- "'MURD[MENT FIE
A1
TRCTOR TO CONVECT THE ABOVE DESCRIBED L)SIBTINO DWELLING
TO THE PUSLIC SEWER. AMOVAIS DAT[ INSl[CTOR'S SIGNATURE
SIGNED THIN DAY OR iD_
OWNER OR NEW HOUSE SEWER
OWNERS AGE-T CONNECT ADDffIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKHOW LIDO[ THAT 1 HAVE READ TH I■ APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ASOVE IS CORRECT AND AOR[[ TO COMPLY
W 17H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL ❑
FLU MB IMO AND ■EWERS.
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR ALTER REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF ■[WAG[DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL ER OF, A ph PLUG AND
RESIDE In, THE D"QRI ED RLID I PR ABAH DON MOUS[SEWER
YIGNATURE PBACKFILL SEFlU TANKS ElOF ERMITTEE •[Q.FITS) u Cw POOIJ
OAMATION ROBERT A. WOOD
M.o. cwEH
SUPERVISING MECHANICAL ENGINEER
2 8 0 5C3 Nov '-"1 1 0 0 . 5.00- ct
i
lap g,4m-C¢BDB A-7/76 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL u
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTYNGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO' ROUl �K "A1 715ATJL ■YBUILDINGADDRSScONMCLocAurrNIA REST STATION DQTCROSS ST. MARHOLE RIP[RINC[ 01VOlOWNER TYPE OF CONNECTION HAIL Y. CUR■ P.L.ADDRESS dl 2541 P.0 ,CO.IMF NO. JOCITY a'TET_ NO.
GAL TRUNK PERMIT NO. ROA
D[SC RI FTI OiI LOT NO.
AFFIDAVIT •Ano EYULL'ET RIICORD:LNSTR.IJO: :D/1TE
BLOCK TRACT .
NO. OF BLDG■.
SIZE OF LOT "aw ON 40T HWY.OR ST:WIDfLNINf;
UBC 6F STATE ENCROACHMEN'C
a ULDING■ A PERMIT NO.
INDUSTRIAL
CONTRACTOR WASTE APPROVAL
ADO I�f/ CHA"ES
CONNECTION CHARD[OX[
CITY TIL. NO.
STAT[ LI REIMBURSEMENT F[[ T+
LICE am HO,. 2 1) C.LA■S __< m *, \ (r,
No. DEH PTIO OF WORK P'[E AI'CRO t�r ALS DAT[= IMSPKCTOR's SIGNATURE
HOUSE■EWER CONNECTING TO CL
TU■ IC SEWOI
A K.■ 'a
[ NEW HOUSE S[wER '
PITS AND/OR DRAINFIEL.D - CONNECT ADDTiJO"A4' r
HOU49 S[WIE1 CON H ECTING TO BUILDING OR WORK \ -
RIVATK DISPOSAL SYSTEM SEPTIC TANK,SEEP.PIT(8)
CONNECT ADDITIONAL■ .OR AND/OR D"INIII[LID
WORK TO HOUfr S[W[R - 0
OVERFLOW SEEPAGE PIT.DRAINFIIED C[JSPOOL ❑ DMYWELL ❑
[riTN.. ■POOL.DRYW[LL-MANHOLE�
T
AIR OR A N OO ■ [
ALTER.REPAIR.SW[R OR
SEW"OR DISPOSAL SYSTEM SEWAGE DISPOSAL■YSTW
DISCONNECT PLUG AND
ABANDON HOUSE 517WER -
BACKFILL S['PT}+,C TANKS ❑
■t[P.PIT(8) LJ CESSPOOL'S
OWNER'S Issuance Fee s
1 HERESY ACKNOWL[DG[ THAT I HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEF AND STAT[ THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND fTATt E
LAWS RGU-ATING
1 FLAY[ Tl-IX THIS DATE A CONTRACT WITH T [ H[R[IN AM@ CON- PLUM S[NO AND f[W[Rl.
TVACTOR TO CONNECT TH[ ABOVE DEfCRIBICD [AIIFTING DWELLING
TO THE PUSLIC ■EWER. I H[R[SY CERTIFY THAT Y I AN PROPERLY,REOI■TA TitD/OIR
br
LIC[Nf[D AS REQUIRED BY LOS ANGLES COUNTY AHD ND ■YAT[ bF
SIGNED THIS DAY OF lo_ CALIFORNIA OR THAT I AM THE LEGAL`OWNER OF. AND INTEND TO
QWN[R OR RESI D[ T [IN, HABOVE U RIMED R ID[NTIAL .RDPKxry.
N ERS AGENT SIGNATURE
OF P[RMTTTE[
K.
M.0. CASH
1. 911 241 9.� 0