HomeMy Public PortalAbout9814 GARIBALDI AVE_Sewer__ i- X4 J71, C�7-y
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APPLICATION FOR PERMIT
COUNTY of LosTY ENGE
DNG IISEWER—SEWAGE DISPOSAL
EpASTD�NT OF COUNTY �
B=ING AND SAFETY DIVISION FAD
INGCIE
T■18RTF W ILLrITYSTFOE APPLICANT TOFI(L�L IN S ST.LKOALf
DESCRtIPTION LOT NO.�• �D' /] p/ $ f r Q p OWNER r`
MAIL
BLOCK TRACT G ADDRESS
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NO. OF ■LDGS.
SIZE OF LOT 6 e too NOW ON LOT CITY TEL NO.
US[ OF
BUILDINGS DISTRICT NO GROUP yAP F/RO^C��«^EY
CONTRACTOR y / ��O'� /
ADDRESS CONNECTION DATA
CITY TEL. NO. 6 STATION rI .}� DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. L / Z, B COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURE P.L M.L TO P.L
PUBLIC SEWER 80.00
P.C.NO.
SEPTIC TANK,SEEPAGE P OR
PITS AND/OR DRAINFYELD 810.00 CO.IMP.NO. JOS No.
HOUSE S[WKR CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 77.00
CONNECT ADDITIONAL BLDG.ORV 0 AFFIDAVIT I EAIRR I EAn[[rr RECORD.INS-M.NO. DATE
WORK TO HOUSE/EWER 83.00
OVERFLOW SEEPAGE PfT,DRAINFIELD
[)(TH.,CUSPOOL.DRYWELL•MAHHOL[0 80.00 HWY,OR"ST.WIDENIN
ALTER.REPAIR A HOUSE
SEWER OR DISPOSAL SYSTEM 41 7.00 STAT[ENCROACHMENT
PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL
O'*� r"nS �T 2 00 CHARGES
yyjrri
Cr CONNECTION CHARGE FE[
AUTHOETLATION roTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH TH[ H[R[IN NAMED CON- REIM■U RS[MENT F[[
TRACTOR TO CO NN[CT THE ABOVE DESCRISED uISTIN" DWELLING p
TO THW[ PUBLIC SE [R. APPROVALS A INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1D_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONN[CY ADDITIONAL
■UILDIP40 OR WORK
ADDRESS
S<TTIC TANK.SEF-P.PIT(S)
I HEREBY ACKNH
OWL[DGK THAT I HAVE READ THIS APPLICATION AND/OR DftAINFI[LD
AND STAT[ THAT THE ABOVE IS CORFtX= AND AGR[[ TO COMPLY
WITH ALL COUNTY ORS
EDINANCES AND TATE NG LAWS REGULATICESS POOL ❑ DRYW[LL ❑
PLUMBING AND SW[RS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED, AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM 7H[ LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
R[SIDC IN, THE A■ 'RI ID[NTIAL P PERTY. ASANDON HO
USE SEW[R
■IGNATURI D BACKFILL S[P-UC TANKS ElOF P[RMIT7g SEEP,PIT(S) LI CESSPOOLS
VALIDATION ROBERT A. WOOD
M.O. CATH SUPERVISING MECHANICAL ENGINEER
CK.
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