HomeMy Public PortalAbout9613-15 GARIBALDI AVE_Sewer__ DEPARTMENT OF COUNTY ENGRV EER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
CASSATT D. GRIFFIN, Sua,T or BUILDING ADDRESS
FOR APPLICANT TO FU IN LOCALITY
BUILDING rit NEAREST
ADDRESS �� J CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. c
NEAREST ,J _ A I J
CROSS ST RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
C `
MAIL ® USE ZONE OCCUPANCY MAP
ADDRESS BK PG
CITY, 1 1 JJ TEL.NO.,4
CONTRACTOR 'A=� CHARGES REIMBURSEMENT FEE
ADDRESS .?'' .�+ 7� L �.� .,� REQUIRED
i
NOT REQUfRED
CITY , pd-i ,f � TEL.NO! )OB N0. CONNECTION CHARGE FEE
STATE
REGISTRATION NO. ? r
Z7� COUNTY CO.IMP. NO.
LEGAL J RECEIPT NO. DATE I BY
DESCRIPTION LOT NO
BLOCK TRACT f 7 WAIVER FOR RECORDING
SIZE OF LOT rLJ NO.OF BLDGS. RECEIPT NO. I DATE BY
NOW ON LOT
USE OF
BUILDINGS TRUNK PERMIT NO.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLICSEWER @ $ 3.50
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1.00 I PERMIT NO.
CONNECT ADDITIONAL BLDG.OR I INDUSTRIAL
WORK TO HOUSE SEWER I.Oo WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 ( STATION > `1 DEPTH
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I MANHOLE REFERENCE /
CESSPOOL—DRYWELL _UPPER / +�i:OWE-R•
SPECIAL CONDITIONS ONLY 2.00 I TYPE OF CONNECTION LENGTH FROM
Y., CUBS_ 'pl M.L.TO P.L.
OWNERS PERMIT $ I 1 00
AUTHORIZATION I TOTAL FEE
HAVE DATEED
CO TRACTOIR TO CONNECT THTE ED ABOVE D SCRIBEDWITH THEI EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE
NEW HOUSE SEWER
SIGNED THIS-v--7----------DAY OF--- ------• ----••------------------ I?�v? -
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT ...... ...... . .. ..... .............
�t (L
" SEPTIC TANK,SEEP.PIT(S)
ADDRESS'x'tl.........t �...:.................................. ------- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL I]
CAT
IONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THATRE AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DE$(`,IfiBEp RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
f�
SIGNATURE SEEP.PIT(S)� CESSPOOLS
?• a. r' .v " ,� ...,�"
OF PERMITTEE------° -°-------- --- --- ...............
76A642D 663 12/52
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