HomeMy Public PortalAbout9803 GARIBALDI AVE_Sewer__ DEPARTMENT OF COUNTY ENGINLER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES I BUILDING
WILLIAM J. FOX, COUNTY ENGINEER
ADDRESS_
FOR APPLICANT TO FILL IN LOCALITY ��e
BUILDINEAREST
G
SS '�- /����� �•)��/ CROSS ST. C � �
ADORE (' (` f7
LOCALITY A 1
DISTRICT NO. A SERIAL NO. PERMIT NO. C
NEAREST 2 0 J
CROSS ST, ! • j —T_
RECEIVED BY Ready for Inspection D/ ISSU D
OWNER
MAIL
ADDRESS USE OCCUPANCY BIC P PO
.�
CITY TEL.NO. yS7/7
CONTRACTOR —2 { i /3 32
CO.IMP.N0.
ADDRESS s °
A JOB.N0.
CITY TTE/L.NO. 1 TRUNK PERMIT N0.
REGISTRATION NO. // COUNTY ROAD PERMIT NO. � :zLEGAL
DESCRIPTION OT N0.Z � Z STATE ENCROACHMENT
PERMIT NO.
BLOCK TRAC INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT HOZ NOW ON LOTS CHARGES
USE OF
BUILDINGS _ CONNECTION CHARGE F
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $ 3.50 RECEIPT NO. DATE (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 7 `'�/ DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00MANHOLE REFERENCE
.1�, 7 y,�PlR LOWER
V YPE OF CONNECTION4000- VLENGTH FROM
OWNERS PERMIT ; I oo Pat M.L.TO P.L.
r
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS....... ._.......DAY OF..�.__ _�'� 19-__ NEW HOUSE SEWER
CONNECT ADDITIOKNAL
OWNER OR BUILDING OR WOR
OWNERS AGENT .. :_7---r 1._ ...._.»_.. _..-•---.._.._..-- --.--_.._..._ SEPTIC TANK,SEEP.PIT(S)
ADDRESS.........- i.---.---------.----.-----_------_._....----_------------- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL[:] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
LAND/OR
TING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
REBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGANDATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-THE ABOVE D€SCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)E) CESSPOOLS�URE il"'O ..Va.-{{� ;MITTEE- -.�_. ..�....__....1--•----._...---••--•---.._.._.-----•--------
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