HomeMy Public PortalAbout9935 GARIBALDI AVE_Sewer__ • R _ MPU CITY
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6A64 2D 5-65
7APPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMBIE,County Engineer ADDRESS
COL \IAN W. JENKINS,Supt.of Building 9935 Z. Garibaldi
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. lRewl and
[DESCRIPTION
LEGAL LOT NO. OWNER Z A e
MAIL
OCK TRACT ADDRESSNO. OF SLDGS.ZE OF LOT NOW ONLOT CITY C di TEL. NO.
E OFILDINGS DISTRICT NO. GROUP MAP PROCE$4ED BY
CONTRACTOeal ewer BK' IG y.r
quare
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ADDRESS CONNECTION DATA
CITY ]Cj TEL. NO. "1*-2020
STATION DEPTH
LICENSE LICENSE UPPER
NO. CLASS MANHOLE REFERENCE '��
WER
NO. DESCIRIPTION OF WORK FEE TYPE OFC TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CUR P.L. M.L.TO P.L.
1 PUBLIC SEWER C $ 5.00 00SEPP.C.NO.
TI TAN SEEPAGE PIT R CO.IMP.NO. ' JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 /^ O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 6 V
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT I WAIV[II I 1.1.,NT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER C $ 3.00 W
E OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM C $ 3.00
HWY.OR ST.WIDENING
EXTN.,CESSPOOL, MANHOLE C $ 5.00
STATE ENCROACHMENT Z
PERCOLATION TEST @ $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER"S PERMIT a 2 00 CHARGES
AUTHORIZATION TOTAL FEE 00 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE.
SIGNED THIS DAY OF 19_ -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL .
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTAND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER O AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTI PROP TY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION
CK. M.O. CASH
L&3 0 6 9:a FEB 91 0 D 7.0 0
I
808 3-64 APPLICATION FOR PERMIT
76A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING )r p
ADDRESS ✓.J Cr /� / Z-,6 I
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building `
LOCALITY ,(� H10-1L(�/�
�T
FOR APPLICANT O FILL IN CROSS NEARESST. & /L&) c'LEAL
DESCRIPTION LOT NO. OWNER T -;PA9 A Q F
/t✓ )4�/�
/ MAIL 2- �Ik G/`"7 c- O
BLOCK TRACT ADDRESS D
NO. OF BLDGS. [�
SIZE OF LOT NOW ON LOT CITYAKc ,%,D1 TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP BK PG MAP PROCESSED BY
CONTRACTOR
ADDRESS �. / CONNECTION DATA
CITY om TEL. NO. 4"14,ar'.pl STATION DEPTH
8 STATE UPPER
REGISTRATION NO. COUNTY MANHOLE REFERENCE LOWER
NO. CESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER a $5.00 P.JOB NO,C.NO.
d
SEPTIC TANK,SEEPAGE PIT OR }
CO.IMP. NO.
PITS AND/OR DRAINFIELD � $10,00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIV[A I [AftIAtNT RECORD.INSTR.NO. DATE OL
WORK TO HOUSE SEWER $3.00 Q
OVERFLOW SEEPAGE PIT,DRAINFIELD h
EXTN„CESSPO O L,DRYWELL,MANHOLE $5.00 V
ALTER,REPAIR OR ABANDON HOUSE O HWY. OR ST,WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 � STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 2 Oo
AUTHORIZATION TOTAL FEE 0 O CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWF� APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS `` DAY,OF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE R AD THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
LRELSIDE
OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
THE ABOV DESCRIBSFg////?RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
//'7BACKFILL SEPTIC TANKSTTEE_ - ! L- SEEP.PIT(S) ❑ CESSPOOLS Q
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAL02 7 2 8w- JU22 1 0 D 5.00-