HomeMy Public PortalAbout9931 / 9227 GARIBALDI AVE_Sewer__ 76A 642D-CEe06 A-71/76 APPLICATION FOR PERMIT -
-SEWER—SEWAGE DISPOSAL.
COUNTY OF LOS ANGELEQ
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR-APPLICANT TO FILL IN OISTRICTMO. SAQUP [� MAR '[ f,7Lo
cEIIED er
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TRUNK PERMIT NO. ROAD PCIMIT NO,
DESCRIPTION L6T NO.
AMDAVIT •Amm [u[■ RECORD.IIjSTR.NO. DATE
BLOCK TRACT
NO. OF LDOS.
SIZE OF LOT NOW O LOT HWY.OR I'f.WIDENING
UQ4 OF STATE[NCROACHM[NT
BUILDING■ PERMIT NO.
-COMt RACTOR _ O INDUITRIAL
15 WASTE APPRQVAL
CHAROCt
ADDREM
CONNECTIONCHA"K FEE
CITY . NO. 0:
STATE //��//�� �j LEL` ..Nu RI[MENT F[[ V
LIC[NSR NO, I..L� ✓ CiAfi
Ho.. DESCRIPTION OF WORK FEE APPROVALIS. DAYE M*PECTOR•S SIONATURE y�
HODS[ [
SW[R CONNECTING TO a,
PUALIC SEWER l y
I K.• AG[PIT OR Ii[Y�HOUSE SXVfXR
.IT.../OR DKAINFI[LD CONNECT ADOITIONAL
HOUSE SEW[RCONNRCTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC T.�NK.SEEP,PIT(S)
CONNECT ADDITIO L BLDG.QR AND/OR DRAINFI[L.D
WORK TO HOUSE SEWER
OVIRFLOW SEEPAGE PIT.DRAINFF[LD CESSPOOL Cl DMYWYLL ❑
U(TN., ESSPOOL.DRYWELL.MANHOLE 4
ALTtR.R AIR OR AfA ALTER,REPAIR.SEWER OR
■EWER-6 DI/PO/AL■YST[1L 46 SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON NOUS[SEINER
RACKP+Lk SEPTIC TANKS ❑
SEEP.Prrt*) ❑ culPoou
ovnMws y� Issugnce Fee $
AU 1I1QL11411T101� TOTAI. FEF AMDHERESY ST/1T[THAT [ ASC THAT I HAVE R[AD THIS /�PPL`CATION
BQ VE I• COR RK
AND AOR[[ tQ COMPLY
• WITH ALL COU MTX ORDINANCES Ob STATE LAWN REGULATING
I HAVE AT THIS DATE A CONTRACT WITH TTI[ HIR[IR NAMED CON- PLUMBING AND I[WERS.
TRACTOR to CONNECT THE ABOVE D[SC BED I HEREBY CERTIFY THAT ['AN WROPERLY .R[GISTIEPMP ANP/OR
TO THE Ptl■LIC •
41C[N/ED AS AEOUIn[D ■y- LOS ANGLES COUNTY AND STATE OF
$It3NED TI-im DAY OR 19 CAIIFORNIA•OR THAT I AM THE IEQAL QWNkR OF. A'ND INTEND TO �
OWNER OR RCSID[ IN, TH[ AM DEN G SCD R"IDENt1AL PROPEJTY.
OWNERS AGENT -
SYONATURE
OF P[h M1TTi[
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ATION
WOR ERS CONIPEI�S T �I,D. CAEH
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