HomeMy Public PortalAbout9441 GARIBALDI AVE_Sewer__ DEPAItrls ENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I ADDRESS
FOR APPLICANT TO, FILL IN LOCALITY
BUILDING NEAREST
ADDRESS ���� ��� � CROSS ST.
LOCALITY GD DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL �I ���
ADDRESS I USE ZONE OCCUPANCY I BK MAP PG
CITY e TEL.NO.
CONTRACTO . , CO.IMP.N0.
ADDRESS
_ JOB NO.
CITYTEL.NO. / TRUNK PERMIT NO.
A ATE
REGISTRATION NO. v� COUNTY ROAD PERMIT NO.
LEGAL ,y'
DESCRIPTION LOT NO. . ` STATE ENCROACHMENT
PERMIT N0.
BLOCK TRACTINDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.BF BLDGS.
Q Q NOW ON LOT CHARGES
USE OF J
BUILDINGS ✓�lIi®f1G�C �j'lflj� CONNECTIDN,CHARGE FEE
NO. DESCRIPTION OF WORK FE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE-
PUBLIC SEWER $ 3.50 RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO I..
PRIVATE DISPOSAL SYSTEM 1.00 rt
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO" I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM `
OWNERS PERMIT $ 1 00 Y. CURB P.L. - M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THEE PUBLIC SEWER ooh/
SIGNED THIS_._`{._.......DAY OF--� ��_ 19....... NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
/
�u 1 '_I -------------- ---• BUILDING OR WORK
OWNERS AGENT................ .....
ADDRESS...ov �(._ ,/'.!�S/G,f/_'.____ SEPTIC TANK,SEEP.PIT(S)
----........ - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL El DRYWELL
CA
TIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR HAT I AM THE LEGAL OWN-
ER OF THE ABOVE ES CRIB RES ENTIAL PROPERTY. BACKFI LL SEPTIC TANKS El
SEEP.PIT(S)[] CESSPOOLS 1
SIGNATURE
OF PERMITTE ----------------•--------------
76A642D 663 1/53