HomeMy Public PortalAbout9827 GARIBALDI AVE_Sewer__ 76AG42D APPLICATION FOR PERMIT 1
11&E.663 11.55
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County Of LOS Angeles G
ADDRESS t
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY T
FOR APPLICANTTO F L CROSS sT.
LEGAL
DESCRIPTION LOT N0. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
01
CONTRACTOR 1�
ADDRESS iz L — �— // 9- 1' ! CONNECTION DATA
CITY A TEL. N0. 4 1J lcp�lpo STATION DEPTH S
MANHOLE REFERENCE
�,
[_1 STATE /
REGISTRATION N0. % !J ❑ COUNTY
NO. DESCRIPTION OF WORK— fFEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH-FROM
PUBLIC SEWER @ $3.50
Y. CURB L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP.NO. JOB N0O �j
N .
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE L
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK -
OWNERS AGENT
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 ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. �. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PITS) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. d.0. ASH
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