HomeMy Public PortalAbout9510 GIDLEY ST_Sewer__ 4= APPLICATION'. FOR PERMIT ],
" DIVISION OF BUILDING AND SAFETY S EW E R—S EWAG E DISPOSAL
Dep-t -nt of C =Iy Engb2&w
Cmc Of Lon Augalr OUIL SG I
WM.J. FOX. COUNTY ENGINQR
CASSATT D.GRIFFIN, DUr'T Or SUUmING LOCALITY
FOR APPLICANT TO M IN
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT TAIL
ADDRISS
NO.OF BLDGL
SIZI OF LOT NOW ON L CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NO. GROUP YAP
K rG
CONTRA CTO -71
ADD CONNECTION DATA
CITY L. X0. / STATION DEPTH
of 6TATE ,� MANHOLE RIFERENCE
REGISTZATIOX NO. of ❑ COUNTY -URPQR— LOWER
TYPE OF CoNXECTION LENGTH FROM m
NO. DESCRIPTION OF WORK FEE 7 URB P Y.L.TO P.L
HOUSE SEWER CONNECTING TO
_PUBLIC SEWER • Q $ 3.E0
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. JOB. NO.
WORK TO HOUSE SEWER 1.00 ,
ALTF�R OR RE-PAIR EXISTING,
OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
SEW _
DISCONNECT AND ABANDON SEWER STATE EXCROACHMRNT
AMD/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAIXFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY Y.00 CHARGED
CONNECTION CHARGE FEE
OWNEH'S PEMMIT s o0
AUMOF=TION I TOTAL FEE ,S' REIMSURSEMEXT FEE
I HS AVE THIS DATE CONTRACTED WITH THHEREIN NAMED CON, � APPgOVAI.S DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EYIfTIXG DWELI.INO
TO THE PUBLIC SEIYER
SIGNED THI AY OF y,' HE* HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR W��O££RPPK
ADDRE9 AXD%OIITDIAINSFIELDP��II
I HEREB ACKNOWLEDGE THAT I HAG FU AD THIS APPLICATIGN CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AOREI TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTQt, fi-
PAIR SEWER OR
PLUMBING AND EE'1fHRI. SEWAGE DISAAL SYSTEM '
I HEREBY CERTIFY THAT I AN PROPERLYpEGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELX5 COUNTY AND STATE OF DISCONNECT PLUG AND
CAUFORXIIA OR THAT 1 AM THE LEG ER OF THI VI ABANDON HOUSE S6lWIR
DESCRIBED RXSIDENTIAL PROPERTY. / BACKFILL D C TANKS
SEItP rrz s c10EaPc» 1
SIGNATURE
OF PERMITTER -
WILLIAM J. t*OX. COU t VALIDATION
_L3 5 8-3n Xff 10 4 8,50
by -
DEPUTY EPU
ET By
.m DEPUTY DILPOTY
C`/O/'-°` APPLICATION FOR PERMIT
�eAe4ED COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIV18ION FU
JOHN A. LAM$IE, COUNTY ENGINE«COLEMAN W. JENKINS. SUPT. OF BUILDING
FOR APPLICANT TO FILL IN
DESCRIPTION LOT NO. OWNER
MAIL
EL OCK TRACT ADDRESS
NO. OF BLDG■.
DIZE OF LOT NOW OM--LOT CfTY TLL. NO.
USE OF DISTRICT NO. GkOUP MAP PROCLI ED BY
BUILDINGS ■K PO
CONTRACTOR S/O� IC h
ADDRESS - CONNECTION DATA
CITY TEL NO. Z STATION 4+ DEPTH 6
STATE LICUPPER
LICEN8[ MANHOLE REFERENCE617,3
NO. •DE CRI ION F WORK FEE TYPE OF C,on N[CTIO LEN TH FROM
HOUSE SEWER CONNECTI NO TO Y. ILIR P M.L.�O P.L_
_ PUBLIC/EWER [5.00 P.C.NO. O
SEPTIC TANK.SE[PADE PTT OR / JOS NO. V
PIT/AND/OR DRAIMFI ELD 510.00 CO.IMP.NO.
HOUSE SEWER CONNECTI NO TO TRUNK PERMIT NO. ROAD PIRLfT NO. ix
0
P
PRIVATE DI■ OSAL SYSTEM $5.00
CONNECT ADDITIONAL SLOG.OR AFFIDAVIT I SAA 11 —KMI- RECORD.MSTR.NO. DATE r
WOR!(TO MOUSE/EWER S3.00 �LLJJ
OVERFLOW■[[lA0[PIT.DRA IN FI[L{7 d
[KTM..CESSPOOL.DRYWELL MA NHOL[4 $3.00 fn
AL R.R AIR R ABANDON O HWY.OR ST.WIDE-14111410 Z
■[WMR OR DIBPOSAL SYSTEM S3.00 STATE KNCROACHME _
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OYMER•S PERMITs 2 Do
CONNECTION CHARD[F[[ CHARD[/
AUTHORIZATION TOTAL M T
/v
I MAV[ AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO C0NN[CT THE ABOVE DESCRIBED G(ISTINO DW[LUNO
TO THE PUBLIC SEWER. APPROVALS DATE IN/P[CTOR'S SIGNATURE
SIGNED THIS . DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNER/AGE NT
CONNECT ADDfTIONAL
BUILDING OR WORK
ADDRESS 2KFTIC TANK.■[Er,PIT(■)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THE/ APPLICATION AHD/OR DRAINFI[LD
AND STAT[ THAT THEASQVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE/ AND STAT[ LAWS REGULATING
PLUM IND AND SEW[RS. CE/e POOL ❑ DRYWELL ❑
I HEREBY C[?tTIFY THAT I AM PROPERLY R[DISYER[D AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED By
LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIPORN IA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO 9;;�tc'!DLS
REDIDEIN, THE ABOVEDESCRIBEDRESIDENTIAL PROPERTY.•IOnATUR[OF PERMTTTEE
VA=ATION JACK R. ALLEN
cK
M.0. CATH SUPERVISING MECHANICAL ENGINEER
7 1 3 Offi my 4 1 0 ® 5.0 Q M v