HomeMy Public PortalAbout9613 GIDLEY ST_Sewer__ ec'IC`SOG
414RD : APPLICATION FOR PERMIT
7§,A�41D .
COUINTT OF LOS ANGEL ffi SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DNWON BUILDING
JOS JL R AHRTR_ ew ADDRESS
WMLI M A. IENaE31, asap'of 8> v
LOCALL TTY
I NEAREST
FOR APPLICANT TO FIII INLtLaAL
DR°°• 'T
DESCRIPTION LOT NO.'��Q OW NUI
MAIL
BLOCK TRACT l ADDRESS
NO, OF BLDGB.
SIZE OF LOT -rr NOW ON LOT I CITY TEL NO.
US[ OF
BUILDINGS f1., DISTFUCT NO GROUP MAP BY
_zkBK PG
CONTRACTOR
ADDR[ee d- CONNECTION DATA
CITY NO STATION DEPTH -
R[GISTIV.TION NO. 1-11OU� MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WQRK FE[ TYPE of c Rolf LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CUR P.L M.L.TO P.L
PU ISL Ic SEW KA $5.00 P.C.NO.
• ICTANK,SCXPA [PITOR Cb.IMF.NO. -108 NO.
FITS AND/OR DRAINFI ELD j10.00
HOUR[§[W[R CONMKCTIMG TO
PRIVATE DISPOAAL SYfTEM 0 $3.00 THUNK PERMIT NO. ROAD PERMIT NO.
CONN[ ADDITION( ■ .OR AFFIDAVIT [AALI [Ala DT RECORD.INSTH.HO. DA
WORK TO HOU§E SEWER 41 $3.00
OVERFLOW SKKPAGE FIT.DRAINFI[LD
[%TN..CKASFOOLDRYWELL.MANHOLE 0 ".00
A LTI R, AI O ABA[ DO OUf HWY.OR ST.WIDENING
'eW[R OR DISPOSAL&Y= 7.00 STATE K.NCROACHMUiT
PERMIT NO.
IN15U5TRIAL
WASTE APPROVAL
O •S CHARGES
FERMIS' s z 00
CONNECTION CHARGE FEC
AUTHOATZF►TION TOTAL. FEE
1 HAVE AT THIS DATE A CONTRACT WITH THC HEREIN AHED CON- R[IMBURSEM[NT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED QIfTING DWELLING
TO TH[ PU■LIC S APPROVALS T INSPECTOR'S SIO R[
SIGNED THIS Y 0pr. /yG Ip�
OWNER OR NEW HOUSE SEWER
OW14[R1 AG[ CONNECT ADDITIONAL
ADDREBS BUILDING OR WORK
SEPTICI H[R[BY ACKNOWL[DG[ THAT HAV[ R[AD THIS APPLICATION AND/O TANK, FIR PIT(f)
AND STAT[ THAT THE ABOVE le CORRECT AND AOR[[ TO COMPLY AND�OR DRAINFI[LD
WITH ALL COUNTY ORDINANCCD AND STAT[ LAWS REGULATING
PLUMBING AND $[VERS. CESSPOOL ❑ DRYWELL ❑
I HER['BY CUTTIFY THAT I AM PROPERLY REGISTERED AMP/OR ALTER.REPAIR.SEWER OR
LICE ED ED AS R[OUI BY LOB A LL COUNTY AND STATE OF SEW AG[DISPOSAL SY1T[ll
CALIFORNIA OR TH 1 M TH[ [R OF. AND INTEND TO DI ONN[CT PLUG AMC)
RESIDE IN. THE VI ESC R [§ TIAL PROP ABANDON HOUSE§EWER
SIGNATURE
OF PERACKFILL S[—�µ1C TANKS: ❑ \
PTT(e) LI C[BSPOOLA G
MMAITON ROBA. WOOD
CK.
M.0. gAAH SUPERVISING MECHANICAL ENQINEER
L 0 7 1 b 7',--o- JJL o 1 0 D 7.L ON