HomeMy Public PortalAbout9448 GIDLEY ST_Sewer__ C680e 3-64
APPLICATION FOR PERM[
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COUNTY OF LOS ANGEIM SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUELDING AND SAFETY DIVISION BUILDING
JIOHN�A. T t,1f11TR_ Coo= En ••r ADDRu•
WILLIAM A. IEIfSEA, Sny'E at B.n�q GE T
LocALITY
N EA R[fT
FOR APPLICANT TO FILL IN `ROSS •T•
LEGAL
DESCRIPTION LOT NO. OW-N[R
MAIL
ALO-CK TRACT ADDRESS G/dG�"
NO. OF BLDOB.
Slit OF LOT FLOW ON LOT CITY �� TEL No.
US[ OF DISTRICT NO. OROUM MAF PROGISIID■Y
BUILDINGS
f ■K Pd
CONTMCTO
ADDRESS 1 e- / CONNECTION DATA
CITY �y TEL. N 6.1.3 P /TATION DEPTH
R[OISTRATION NO. / / O /Z cou wry, MANHOLE F1[F[R[NC[
NO. DESCRIPTION OF WORK FEE TYRE OF CONNECTION LENOTH oM
HAUS[•[W[R CONNECTING TO Y. CUR■ P.L. M.L.TO
PUBLIC SEWER 60.00
• IC NK,■ AO[P OR P.C.NO.
PITS ArID/OR DMINFI[LD t •10.00 CO.IMR�NO. JOS NO. d
HOD11
S[SEWER CONNECTING TO TRUNK PERMIT NO. ROAD P[RMfT NO. O
PRIVATE DISPOSAL SYSTEM 4 65.00
CONNt&t ADDITIONAL■LDa.OR AFPIDAVIT I •AIr[II LAIDI[R RECORD.INSTR.NO. TE Ix
WORK TO HOU•[SEWER 63.00 O
O
OVERFLW 6K PAGE PIT,DRAINFIELD r
EICTN.,C[DSPOOL,D LLIIANEIOLK d 60.00 HWY.OR ST.WIDENING LYvi
A DO OUSE
a
•EWER ■YS.TEM 02,00 STATE ENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WAST[APPROVAL
CHARGES
OWNERIS PERMT 0 2 00
CONNECTION CHARGE FEE
ADTHO&IZATION TOTAL FEE
'1 HAVE AT THISDATE A CONT7IACT WITT
H HE HEREIN NAMED CON- REIM•URS[MENT FEE
TRACTOR TO C0SH[CT TH[ ASOVI< D KD EXISTING DWKLLI
TO TH[ PU OLIC • [ S
OVALS DATE INPECTOR'S SIOHATUR[
SIGNED THUG 4 4 nA'y
OWNER OR NEW Hous[SEWER
OWNERS AO[ CONNECT ADDITIONAL
ADDRL■ ■UILDINO OR WORK
I HEREBY ACKNOWLEDGE AT HAV[ READ THIS APPLICATION ■ND/O TANK,S[IEL PITS)
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OLPTICR DRATr-ISfN FIELD
WITH ALL COUNTY ORDINANCES AND •TATE LAWS REGULATING CESSPOOL LJ DRYW[LL Cl
PLU Me
AND SEWERS.
I H[RKRY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR _
LICENSED AS REGUIRrD Sy AN
ANGLES COUNTY AND 9rrATZ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PL O AND
RESIDE 4Ni THE ASO D[SCRI I ED 1t IAL PROPSRTY,
A SAN DON NOUS[SEWER
SIGNATURE I�
OF P[R 41TTQ RACK ILL• C TANKS LJ
•[Q.PIT(•) CESSPOOLS
VALIDATION OBERT A. WOOD
cK. M.o, CASH SUPERVISING MECHANICAL ENGINEER
LAC067 d 9% X17 1 0 0 5.00- $
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