HomeMy Public PortalAbout9442 1/2 GIDLEY ST_Sewer__ DEPART,IVIENT OF COUNTY ENGL'STEER SEWER-SEWAGE DISPOSAL 1
t DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
• COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLIPA TO ILL IEJ LOCALITY Q E Ef�®
BUILDING // NEAREST
ADDRESS CROSS ST. QvE�
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST -5 A S
-o o/� /�'-7._.3
CROSS ST.
RECEIVED Y Ready for Inspectien DAT ISSU
OWNER
MAIL USEZONE OCCUPAaN,CY
ADDRESS4 14 4 dMfdl�
BK PG
CITY .., ! � TEL.NO. r yam'
CONTRACTOR kQ r- CO.IMP.NO.
ADDRESS ✓ A JOB.N0.
CITY �t EL.MO Q /J
J TRUNK PERMIT NO.
REGISTRATION NO. / Y917 ® STATE
COUNTY ROAD PERMIT N0.
LEGAL .�� STATE ENCROACHMENT
DESCRIPTION LOT N0. 77, — PERMIT NO. �+
BLOCK TRACT�� Q{ SfJN ,pA�/L/SrYir WASTE
APPROVAL
SIZE OF LOT X Z / N0.W OF ON BLOLDTG". CHARGES
NO
USE OF
BUILDINGS 11'1.."t"r`: !- CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER S 3.50 RECEIPT NO. I DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITSAND/ORDRAINFIELD 2.00 STATION / �� DEPTH
CESSPOOL—DRYWELL /
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
Y ---Gow5" M.L.TO P.L.
OWNERS PERMIT s I 1 00
AUTHORIZATION TOTAL FEE Q
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS...___...........DAY OF...._......___.____._____ 19..._._ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
T..........._. BUILDING OR WORK
OWNERS AGENT
-------------•-----.-•------•--•---••-.--------.�.
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........................----•-..........--•----......_......-•._.......-.........._... AND/ORDRAiNF1ELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL(] DRYWELL❑
CAT
IONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN.
ER OF THE ABOVE DESCRIQD RESIDENTIAL GfE TY. BACKFILL SEPTIC TANKS
SIGNATURE /('/U�JL. �J SEEP.PIT(S)0 CESSPOOLS
✓
OF PERMITTEE---- -••-----5^.--r .....
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