HomeMy Public PortalAbout9662 GARIBALDI AVE_Sewer__ APPLICATION- FOR PERMIT 1
DIVIMON OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
D.parbu al of Comitt Fnubm.x
Cmmt7 of Los Juvelr BUILDING
Will.,1. IFOX.COUK Y MHGLHX§1 ADDRM
CA GATT D.GRIFFIN,Gur r or tun_ ine L CALITT
FOS APPLI TO FILL IN "
LI{GAL
DESCRIPTION LOT NO. OW AER
BLACK — T2ACTK 1.
MAIL
ADORE"
NO. OF BLDG$.
SIZE OF LOT OY ON LOT 'Cr" TEL. NO.
USS OF
B IN DLSTRICT No. GROUP YAP
BK PG
CONTRACTOR
ADDRESSJA COME=ON DATA
CITY TEL NO. STATION DEPTH
TATE MANHOLE kEFERENCE
REGISTRATION XO. ❑ COUNTY L WriR
No. DESCRIPTION O W FEE
HOUSE FEWER CONNECTING TO TYPE 0 X-ECTIOH LENGTH FROM
Y. P.L M L TO P.L.
PUBLIC SEWER 3.50
HOUSE SEVEONNECTING TO
PRIR C
VATE DIS AL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR P. C. N0.
YORK TO HOUSE SEWER 1.00 CO. IMP. MO. JOB N0.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL RYSTEY 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT ANDABANDOSTATE N SEWER ENCROACHMENT
$AND/OR DIIrySPOySAL Y 1.00 STATE
NO
J YITIC TA ,
B AND/0 15RA NFIRLDT OR 2.00 INDUSTRIAL
JPEPOOL-DRYWELL VIA=APPROVAL
IAL CONDITIONS ONLY 2.00 CHARGES
OWNEH'S PEUCT S 00 CONNECTION CHARGE FEE
AUMO=ATION TOTAL FFM REIMBURSEMENT FES
I HAVE DATE WITH THE _47rom.
TRACTORTTOSCON ECT TTHEACTED ABOVE DESCR BEDHEILELSTING DWELLING APPHOVI" DATE INSPIt'SGIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SERER i
SIGNED THIS SAY OF 19-
OWRER OR CONNECT ADDITIONAL
OWNERS AGENT -BUILDING OR WORK
SEPTC TANK,SEEP,PIT(S)
ADDR AND/OR
GRAINFIELD
1 HEREBY ACKIiq� DGE THAT 1 HAVE READ THIS APPLICATION COSPOOLn DRYWEII�]
AND STATE THAT TH ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH AIL COUNTY ORDINANCEB AND STATE LAWS REGULATING ALTER,REPAIR,SEVER OR
PLUMBING AND SEWERS. ALTER, DISPOSAL ER OR
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AHD/OR
LICENSED AS R[OUIRED BY LAS AHGO.RS COUNTY AND STATE OF DISCONNECT PLUG AND
C&FCALIFO IA OR THAT I THE L[GAL Q OF ADO N HOUSE SEWER
ID AL!
P
LLC TANKS
SIGNA t
IT
D qS
CESSPW ' I •''�`f•.>R r
WIL I "J.FOX,Cou)m EmGmxm VALIDATION R.A.WOOD, CHISF P-mcL INAPWcTpR .
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