HomeMy Public PortalAbout9825 GARIBALDI AVE_Sewer__ .7175ABA2D
CEBOH 11-57 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A. LAMBIE, County Engineer ADDRESS % 6. / :NO.
CASSATT D. GRIFFIN, Supt of Building —LOCALITYNEAREST,, FQR APPLICANT TO FILL IN / CROSS ST LEGAL �DESCRIPTION T�LOT NO OWNER r«-;^' ry fyr ,,BLOCK �' � TRACT. rADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TE
USE OF
BUILDINGS DISTRICT NO. I GROUP I MAP
CONTRACTOR ,, y; , "" K` r:PG
ADDRESS 's r" 1 r.' CONNECTION DATA
CITY TEL.NO..4 c r (•s c% STATION `; -,�., t�.� �•. DEPTH
STATE
REGISTRATION NO. ® COUNTY MANHOLE REFERENCE f .,'UPPER
NO. DESCRIPTION OF WORK F
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 3 TYPE OF CONNECTION. LENGTH FROM E;...,
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 -
HOUSE SEWER CONNECTING TO P.C. N0. !,"•"""`�ij
PRIVATE DISPOSAL SYSTEM @ $1.00 -CO.LMP_
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT N0,
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHAR6 S`^•..
OWNERS PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE : `" REIMBURSEMENT FEE �`
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
A i i
SIGNED THIS DAY OF 19 NEW HOUSE SEWER /-2'
OWNER OR _ t /' CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL❑
LDESCRIBED
L COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
G AND SEWERS.
BY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
IA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
D RESIDENT( PROPERTY. BACKFILL SEPTIC TANKSE ,r,�/ SEEP.PIT(S) ❑CESSPOOLS ❑ITTE
OF VALIDATION ROBERT A. WOOD
CK. M.0. - CMH SUPERVISING MECHANICAL ENGINEER
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