HomeMy Public PortalAbout9548 3/4 GIDLEY ST_Sewer__ 76A
E-..3 12.54 APPLICATION FOR PERMIT
S Q E•861
DIVISION OF WELDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN,SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. do OWNER
BLOCK TRACT " MAIL 1
ADDRESS
SIZE OF LO w!4 10000 V N LOT CITY /jll,�44 TEL. NO. (j USE OF
BUILDINGS DISTRIC�. GROUP MAP
T BK PG
CONTRACTOR ,[.. --r L` T;,
ADDRESS 5 C. CONNECTION DATA
CITY TEL. NO. 1� STATION �' Q, �� DEPTH
P /
' ❑ STATE • MANN E-BEFERENCz� u/ LOWER
REGISTRATION NO. [I COUNTY COUNTY _ J�P
TYPE ECTION LENGTH FROM
NO. I DESCRIPTION OF WORK FEE Y. CURB j P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR JOB. NO.
CO. IMP.NO. /
WORK TO HOUSE SEWER 1.00 _ �( G - - --
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0.•
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHAR
OWNER'S
PERMIT E 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE , ori REIMBURSEMENT FEE.
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- n �[T I�
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DA INSPECTOR-SSIGN�TURE
TO THE PUBLIC SEWER 1-T
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[I DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY 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 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PITS) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTED
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION
"' 7 3 5 1 u 1 SEP ? 4 4.5 0 L''
BY BY
DEPUTY DEPUTY
BY BY
Q DEPUTY DEPUTY