HomeMy Public PortalAbout9541 GARIBALDI AVE_Sewer__ f0-63
76A6A642D APPLICATION FOR PERMIT
64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING t
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS _ y
NO. OF BLDG S. �
SIZE OF LOT NOW ON LOT CITY • TEL. NO
USE OFDISTRICT NO. GROUP MAP PROCESSED BY ,
BUILDING BK PG
CONTRACTOR fA_ 10 -
ADDRESq r ) CONNECTION DATA
STATION Al DEPTH
CITY L. N
STATE [ t/ OWE
REGISTRATION NO. COUNTY MANHOLE REFERENCE a LOWER
NO. DESCRIPTIO OF WORK FEE TYPE(]F.rA4Y�CTION LENGTH FROM !
HOUSE SEWER CONNECTING TO -� Y. ( CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 55.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 /// U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSALS STEM@ $3.00 IM
CONNECT ADDITIONAL BLDG.0 R AFFIDAVIT WAIY[R [A[[M[N7 RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 d
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Vf
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECT
SIGNATURE
SIGNED THIS DAY OF _19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY OERTI FY THAT 'L
AM PROPERLY REG STERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED 5 REQUIRED BY LOSES COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM
C ALIFORN A AT I AM THE LE OWN R AND INTEND TO DISCONNECT PLUG AND
RESIDE I , THE BOVE DESCRIB ESID TI PROPERTY. ABANDON HOUSE SEWER
SIGNATUR BACKFILL SEPTIC TANKS ❑
OF PERMITTEE _ SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAAO 0 9 1 7 MAR 31 1 0 D 7.0 0" G