HomeMy Public PortalAbout9537 GARIBALDI AVE_Sewer__ I
CE8083-62 APPLICATION FOR PERMIT
76A642D
it COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
I BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADORE.. .�
WILLIAM A. JENSEN, Sup't'ot Building
- � LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL )
DESCRIPTION LOT NO. OWNER -
t MAIL
BLOCK TRACT ADDRES .r
NO. OF BLDGS.
1
SIZE OF LOT , O y NOW ON LOT 1 CITY TEL. NO.
USE OF I
DISTRICT NO. GROUP
BUILDINGS �]�� 'y PROCESSED BY
5,06
+ lY BK P
'/
CONTRACTOR L, '0 6
ADDRESS O — CONNECTION DATA
t+ i' STATION DEPTH
CITY TEL. NO. V
STATE MA H L ER
REGISTRATION NO. COUNTY
n LOWER
NO. DESCRIPTION OF WORK9 Fm ITr T10LENGTH ROM
HOUSE SEWER CONNECTING TO Y. P.L.e` M.L.T .L. �)
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
+
PITS AND/OR DRAINFIELD @ E10.00 CO.IMP.NO. JOB NO. • V
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO. ROAD PERMIT a.
PRIVATE DISPOSAL SYSTEM E3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. , ATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHME
PERMIT NO. .{S
-- INDUSTRIA F �r r.
WASTE ROV /q
HARGE
OWNER'S PERMIT s z 0
0
AUTHORIZATION TOTAL FEE CONNECTION C A
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBU¢iSEMEN FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - AP V DATE INS EGyO R'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIO L
ADDRESS BUILDING OR WO
SEPTIC1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
TANK. IELD (S)
AND/OR DR FIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPO ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTE ,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SE GE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A THE LEGAL OWN R OF, AND INTEND TO QA CONNECT PLUG AND
RESIDE IN, THE ABOV RI BE RE D IAL PROPERTY. ,'ABANDON HOUSE SEWER
SIGNATURE ,
OF FERMtfT EE BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK. M.0 GASH SUPERVISING MECHANICAL ENGINEER
rUte, �v/
9703Z03 SEP 310 D 7.00-