HomeMy Public PortalAbout9500 GIDLEY ST_Sewer__ 76250EAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTbIENT OF COUNTY ENGINEEE
BUILDING AND SAFETY DIVISION
F.17._
FOR APPLICANT TO FILL IN
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DESCRIPTION LOT NO. OWNER
DLO-CK TRACT ADDRESS C`% ��-
NO. OF ■LDGS.
SIZE OF LOT NOW ON LOT CITY T TEL. O
USE OF DISTR'c'NO,
GROUP ,
OUMI BY
■UILDINGS
CONTRACTOR F MAP D
MA
ADDRESS jo�fCONNECTION DA
CITY w TEL. HO. ¢ L-el,6 ! STATION DEPTH
�l '' K MAKHOLE R[FERENC[ U
REGISTRATION NO. /i� Y COU KTY
No. DESCRH TfON OF WORK FEE TYPE OF CONNECTION LENGTH M
HQU■E SEWER CONNECTING TO Y. CU Ra
P.L M.L.TO P
PUBLIC SEWER $5.00
F.0No.
■[DTIC TANK.SK GE PI OR Co.
PR
IT/AND/OR DAINFIELD 510.00 CO.IMP.NO. JOE NO.
HOUBE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PE7tMIT NO.
PRIVATE DISPOSAL SYBTSM Sa.00
CONNECT ADDITIONAL SLD AFFIDAVIT •u�[� [Y[II[R RECORD.INSTR.NO. DATE
WORK TO HOU/[S[W[R 55.00
OVER
FLOW/[[PAG[PIT,DMINFI[LD
EXTN.,C ESS POOL,DRYWELL.MAN H OLE $25.00
N 'ON O [ HWY.OR ST.WIDENING d
BEWER Ctta■Y/TEM 03.00 Q STAT[EKCROACHMENT
PERMIT NO.
INDUBTRIAL
WASTE APPROVAL
HA XS
OWNERS PERMIT IS 2 00
I AUTHORIZATION TOTAL FEF d CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH TH[ H[R[IK NAMED CON- FE
REIMBURSEMENT E
TRACTOR TO CONNECT
TH[ ASOVE D RI"D ■
TO THE PUBLIC a APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED TH18 DAY 1
OWNRt OR NEW HOUSE S[W[R
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
A.... AND/GR
TANK.SEEP.PIT(■)
I HKRTT
IAT ACKNOWLEDGE TAT I HAVE READ THIS APPLICATION AND/GR DRAINFI[LD
AHD STATE THAT THE ABOVE 1■ CORRECT AND AGREE TO COMPLY
WITH ALJ.. COUNTY ORDINAN CU AND STATE LAW/ MEGULATIKO
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWLLL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REGUIR[D BY LOS ANGLES AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
s
R ESIDB IN. THE ASOV[ DESCRIBED ID[NTIAL FROP[RTY. ABANDON HOUSE SEWER
SIGNATURE SACKFILL SXPbC TANKS
OF PERMITTEE SEEP.PIT(S) LJ CE/1 POO LB
VALIDA'T'ION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.)
Y.O. CASH
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