HomeMy Public PortalAbout9638 GIDLEY ST_Sewer__ �9A 642D r APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DRIDARTMENT OF COUNTY ENGINEER
DUILDING AND SAFETY DIVISION ■UILDING
1 R
JOHN'A. LAMBIE. COUNTY KNOINtRR ADDRESS G�
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOG L ITT
NGR[1T
FOR APPLICANT TO FILL IN °"°" 'T
LEGAL
D[■CR IFTIO44 LOT NO. OWN"
MAIL
/LOCK TRACT ADDRX" ,
NO. OF SLDO/. r d H
112E OF LOT NOW ON LOT CITI' O� NO. V
U [■ F
BUILDINGS DISTRICT P40A GROUPj PROCLSSED/Y '
/1v/ ■K ro
CONTRALTO c D v �-
ADOREr■ COM(ECfION Dara
CITY T.L.ILZ N D STATION DEPTH
STA LIC MANHOLE R[FE R[NCL PPR
LICENSE NO. tLAp7W '00
NO. DESCRIPTION OF WORK FIE TYPE OF CONNECTION LENGTH M
HOU■C SEWAIR CONNECTING TO Y. CURB P.L. M.L.TO P. '
PUBLIC■[WEA $15.00 ,
• IC A GE PIT P.G.NO.
PITT AND/OR DRAIHFI[LD f10.00
Co.IMP.NO. JOS NO. '
OUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SY•T[M $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT u INLWT RECORD.INSTR.NO. DATE CD
WORK TO HOUSE SEWER SS.00
OVERFLOW SEEPAGE PIT.DRAINFI[LD
C)
KXTH..CLS•POOL.DR�NDON AP4HOLi $15.00 HOUSIEHWY.QR ST.WIDENING V
■ WER SYSTEM 7.00 LV
E
STATE[i1CROACHMQfT �
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
CHAROp
OWNER'S FERMTs z OO
UK
AUTHORMT10N TOTAL [L.E /► CONNECTION CHARD[
y�... i�
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO-N. REIMBURSEMENT FEE
TRACTOR TO.CONN[CT E ASOVE DLSCR SLD ISTING DWELLING
TO THE PUBLIC ■ -71 APPROVAIZ DAT[ INSPECTOR'S SIGNATURE
SIGNED THIS PAY OF 1G
OWNER OR
NEW Houu SEWER
OWNERS AO CONNECT ADDITIONAL
ADD RLS 8411 LDINO OR WORK
SEPTIC TANK.■LEP.PITS)
1 H[R[BY ACKNOWLEDGE THAT.I HAVE READ THIS APPLICATION
AND •TAT[ THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY AND/OR DRAINFI ri n
WITH ALL COUNTY ORDIN CES AND STATZ LAW REOULAT7N0
PLUMS
ING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I ry[R[BY CERTIFY TH M PROPERLY RE01 AHD/OR ALTER,REPAIR.SEWER OR
LICENSED AS R[OUIR[ 0S ANGW COU A RATE OF SEWAGE DISPOSAL•Y■T[M
CALI Fb RNIA OR THAT 1 H[ LEGAL OWN F, INTEND TO DISCONNECT PLUG AND
RAID[ IN, THE ASO IS[D R[■ID L P[RTY. ABANDON HOUSE SEWER
•10HATURE El
K".
POIMI I I SACKF ILL I LFTIC TANKS
BEV.PIT(B) ❑ CESfPOOL•
ALIDATION JACK R. ALLEN
CK Y.O. CASH SUPERVISING MECHANICAL ENGINEEA
► V- 0099c- i%U 5 10 0 5.00-
79A6,4&0 s-u APPLICATION FOR PERMIT
�a waa _ 1
DriMON OF BUrLDING AND SAFETY SEW ER--mSEWAG E DISPOSAL
DspwWamt of Ccr i &minty
Co>m37 of Los Aha*ks 'BUILDING �L '
ADDRItD 6�
WM.J. FOX. CouNTY ENaLNmR
TT 0.GIRIFFINI,SUPIT ow NUMMINO LOCALITY
FOR APPLICANT TO M IN CRM ST.
LEGAL p/
DESCRIPTION LOT NO. to Q OWNmt
BLOCK TRACT13, Q fin'
ADDRESS
NO. OF BLDGf,
SIZE OF LOT Now ON LOT qTrT L NO.
USE of
BUILDINGS DISTRICT No. G� eK MAP G
COIfTRACTO C?
ADDRESS �, COHPM=OR DATA
CITT TEL HO�Q y{��� STATION � O DEPTH a'
❑ STATE lAMHOLE RuERENC[
REGISTRATION NO-
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE ECTIOX LENGTH FROM
PUBLIC SEWER 3.30 T. RB P.L. Y L.TO P.L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADD TIONAL BLDG. OR P. C. N0.
WORK TO HOUSE SEWER 1.00 CO IMP NO JOB N0.
ALTER OR REPAIR EXISTING )
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT 1110. ROAD PERMIT NO V�
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIOMB ONLY 2.00 CHARGED
CONNECTION CHARGE FEE
Ovnm'S PERMT $ 1 00
AIITHORTLATION TOTAL FEE 2p REIYBVRSEMgNT FEE
TRACCTTORTTOSDATE CONNECT THEAABOVEACTED ~ITH THE HMEIN DESCR BED E:XISTINGAMED CON-OWELLING APPROVALS D INSP[ 'DnQtIA
TO THE PUBLIC SEWER
SIGNED THIS SAY OF 19- NEW HOUSE SEWER Z
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUIiDING OR WORK
8 C TANK,SEEP, PIT(S)
AODRE AMD OR DRAINFIELD
I HEREBY ACICM DGE THATHAVE READ THIS APPLICATION CESSPOOL[:1DRYSIELL❑
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COyyPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATIHG ALTER,REPAIR.SEWER OR {
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RUIDENTIAL PROPERTY. BACKFILL S C TAXKD E].
PIT(g) CESSPOOLS
SIGNATURE
017 PKRMIrrEt -
WIL11AM J.FOX.CouwrY ENGINIIR VATS A3= R.A.WOOD.CPUKF Pisa. INSPECTCM
L8737 JUL31 4 450 n