HomeMy Public PortalAbout9723 GARIBALDI AVE_Sewer__ 76A 642D -CE808-10-71 APPLI CA 10N FOR PENT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BI ILDING L
ADDRESS
1ld'� /
LOCALITY NEARESTFOR APPLICANT TO FILL IN 7
CROSS ST.LEGALDESCRIPTION LOT NO. OWNERMAILBLOCK TRACT ADDRESSNO. OF BLDGS.SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF �s�
BUILDINGS �N / DISTRICT 1
�{0M
y{. GROUP BK
AP PROCESSED BtY�,J/
FONT RACTO I'► 3
ADDRESS . -/> CONNECTION DATA
CITU TEL. NO� f !J STATION / -l. i-7 J( DEPTH
ST E LIC _ III I {0f UPPER
�
LICENSE NO. CLASS - Sp4 MANHOLE REFERENCE / f LOWER
NO. 1 DESCRIPTTOR OF WORK FEETYPE OF N TION LENGTH FROM `�
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER G $7.00
SEPTIC TANK.SEEPAGE PIT OR 313
P.C.NO.
PITS AND/OR DRAINFIELD @ f10.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TOTRUNK PERMIT NO. ROAD PERMIT NO���r� / a
PRIVATE DISPOSAL SYSTEM 53.00 d O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I [AS[N[NT RECORD.INSTR,NO. DATE V
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL,DRYWELL. $5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT W
ANHOLE $7.00 PERMIT NO. d
INDUSTRIAL W
WASTE APPROVAL Z
OWNERS PERMIT $1 31 Oo CHARGES
AUTHORIZATION TOTAL FEE O:T CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. 6 APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF Q P_
OWNER OR NEW HOUSE SEWER �',
OWNERS AGENT
CONNECT ADDITIONAL
ABUILDING OR WORK
ADDRESS
r SEPTIC TANK.SEEP,PIT(S)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICAT N AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO PLV
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL [:1 DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY ND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O THAT I AM THE LEGAL OWNER OF, ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH DESCRIBED RES ENT L OPERTY. ABANDON HOUSE SEWER
SIGNATURE -• M
OF PERMTTT BACKFILL 9ey-NC-T*f*FB--Q
'3E'�YMS'MNA'B CESSPOOLS
VALIDATION M.O. CASH
E-663
S&E-663 3.55 ■AP LICA IOY_ FO ■ PERMIT
■
' S&
''.. DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
7of
WM.J. FOX, COUNTY ENGINEER
T), CASSATT D.GRIFFIN, SUF'T OF BUILDING LOCALITY ^
FOR APPLICANT TQ FILL INNEAREST
CROSS ST. �` 1
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT ' * MAIL
- ADDRESS
1.11 J NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
__BUILDINGS -.__ 4.44#t -�/" DISTRICT NO. GROUP MAP
RK PG
CONTRACTOR
ADDRESS � "- g CONNECTION DATA 7-
1
CITY TEL. NO. C, 1¢' '�. STATION mart .`; DEPTH
jjj ❑ STATE MANHOLE REFERENCE
REGISTRATION NO. f ❑ COUNTY ZIL .LOWER
KJO., DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
/ HOUSE SEWER CONNECTING TO .{Y.•� ' CURB P.L. M.L. TO P.L. }
1 PUBLIC SEWER �a $ 3.50 + �•-�-3'`-
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00y /---.d'a+, — -r
CONNECT ADDITIONAL BLDG. OR • P. C. NO.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. J a- _ JOB NO.
Y
ALTER OR REPAIR EXISTING J TRUNK PERMIT NO. ROAD PERMIT NO.�./'!
SEWER OR DISPOSAL SYSTEM 1.00 L ,I -6y�
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OP. DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD +;100 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S S t 00
AUTHORIZATION TOTAL FEE � REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CO -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
OWNERS. AGENT �•Ct BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS _ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR
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