HomeMy Public PortalAbout9960 GARIBALDI AVE_Sewer__ D
IS&E-689 11.85 APPLICATION FOR PERMIT 1
S 8 E•6
,DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER —ADDRESS 4/�/�- -r—� Xo.'?
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGALOWNERs1/�.)
DESCRIPTION _
MAIL ^
BLOCK TRACT I ADDRESS
- v
NO.OF BLDGS. CITY TEL. NO./
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS � T BK PG
CONTRACTOR
ADDRESS
CONNECTION DATA
T^,
�t j % STATION "'� a DEPTH
CITY TEL, N0. `l-- MANHOLE REFERENCE UPPER
�y ❑ STATE
REGISTRATION NO. d ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 P C. N0.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
I /
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0._ ROAD PERMIT NO. + /
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
I -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
,_. CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE
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
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A01PLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 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 I AM THE LEGAL QAUIER OF THE ABOVE
DESCRIBED RESID L PROPERTY. ( BACKFILL SEPTIC TANKS❑ t'
SIGNATURE SEEP.PITS) ❑ CESSPOOLS
OF PERMITTEE
mim
JOHN A. LAMBIE, COUNTY ENGINEERVALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK._ N. 0. CASH
4 8 1 3 i"• APR 4 4.5 ) in
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