HomeMy Public PortalAbout9712 GARIBALDI AVE_Sewer__ DEPARTMENT OF COUNTY ENG1NEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENC3INEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITYBUILDING NEAREST
C
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
A .. c
NEAREST A - Z_ S
CROSS ST.
RECEIVED BY Ready for Inspection I DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY B4CAPPG
CITY TEL.NO. --"-
CONTRACTOR CO.IMP.NO. 1150 l7a
ADDRESS JOB.NO.
CITY TEL.NO. TRUNK PERMIT NO. --
STATE
REGISTRATION NO. 8 COUNTY ROAD PERMIT NO. r
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO. _
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. CHARGE
NOW ON LOT
USOF
BUE DINGS CONNECTION CHARGEFEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
j HOUSE SEWER CONNECTING TO —
!_ PUBLICSEWER @ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO' DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 - MANB���I���REFERENCE'
UPPER
TYPE OF CONNECTION LENGTH FROM
CURB 1':t. M.L.TO P.L.
OWNERS PERMIT S I 00
AUTHORIZATION TOTAL FEE
CONTRACTORHAVE
TO CONNECTR DATE ACTHTE ED ABOVE DESCRIBEDWITH THE I EXISTING ED APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS____________.__DAY NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT------------------ BUILDING OR WORK
____-___._.._.....___.__.______.__-__.. =_-_-__..�.,_ SEPTIC TANK,SEEP.PIT(S)
ADDRESS.......................-- -- -•_....-..:._•_-_•-......_......-•- _.........._... AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] DRYWELL I]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 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 DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SIGNATURE SEEP.PIT(S)E] CESSPOOLS I]
OF PERMITTEE-- - - - ---------- -_----------------------------------------
76A642A 663 7/53 Q„(/-