HomeMy Public PortalAbout9553 GARIBALDI AVE_Sewer__ 76^°42DAPPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—S-EWAG E D I S POSA L
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JOHN A.L.AM81E, CouNTY ENGINEER ESSIn CA LBATT D.ORFFFIN, BUF'T OF BUILDING LITY7-1
FOR APPLICANT TO FILL IN .
LEGAL SO F (y� OwnER GDa IPTIOn LOT XO
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BLOCL76 TBACT i ADDRESS S5--Sn
NO.OR BL GS.
SIZY OF Lot O OW ON LOT CITY } TEL, NO.
USE OF t DIHIRICT NO. GROUP YAP
BUILDING!
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CONTRACTOR
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ADDRFBD COR2C=OX DATA
ITATION T DEPTH
GITT TEL. N0. MANHOLE REFERENCE LOWER�+BTA LOWER
REGISTRATION NO. ❑ COUNTY .
NO. DESCRIPTION OF WORK K FEE a44
TYPE OF CONNECTIOW LENGTH FROM
HOUSE SEWER CO ECTINO TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER Q j 3.50
SEPTIC TANK,SEEPAGE PIT OR
PITH AND/OR DRAIMPIELD 3.00
OVERFLOW SEEPAGE PI DRAIXF ELD o
EITN.,CFSSPOOL,DRYWEL "do LE 4 2.00 go. IiP. n0. JOB No.
HOUSE SEWER CONNECTING t0 -
PRIVATE DISPOSAL SYSTEM co s 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
Co"
ECT ADDITIONAL BLDp.OR a 5TAT8 EXC9OACHMEXT
WOR TO HOUSE SEWER 3 1.00 p MIT NO. - ..
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISROSAI -V-- (a 11.00 WASTE APPROVAL -
CHARGES
CORRECTION CHARGE FEE _
OWNEH`SPERMIT i 1 00
REI'M-BURSEMENT FES
AUTHORIZATION TOTAL FEE Q
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME CON- APPROVAL$ DATE INHPECTOR'9SIpNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E7CISTING DW�LLING
TO THE PUBLIC SEWER. NEW HOUSE SEVER '
SIGNED THIS TIAY OF l9 CONNECT ADDITIONAL -2 /
OWNER OR BUILDING OR I(ORK Nll
OWNERS AGENT SEPTIC TANK,SEEP.PIT($)
ADDRESS XD/OR DRAIN-FIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT ANP AGREE TO COMPLY
WITH ALL COUNTY OhDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE OISP-OSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LIGEN9ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF 41ECOHNECTPLUBAXD
CA 1fORNIA OR THAT I AN THE LEG OWNER OF THE. ABOVE ABAVUDOX HOUSE SEWER
DESCRIBED REHIDfiM PR PERTY. BACKFILL SEPTICTANKS�
SIGNATURE SEEP.PIT($5 E[ qaSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, CouNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
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