HomeMy Public PortalAbout9642 GIDLEY ST_Sewer__ 4,72
76A642L APPLICATION FOR PERMIT
7664 v
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Y
ADDRESS
L
LOCALITY j /!o
NEAREST
FOR APPLICANT TO FILL IN ROSS 5T.
E
LOT NO. OWNER
DESCRIPTIONLGAL
�., r+ F
MAIL
BLOCK ..TRACT ADDRESS J /'
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF ; DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
t y
CONTRACTOR 1.4 !.•'
ADDRESS jI J r';+f _y CONNECTION DATA
�?
STATION DEPTH
CITY ;j TEL. NO.r
STATE .,«,. LIC, y MANHOLE REFERENCE U1"P[R
LICENSE NO. M "" •.., CLASS - LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM A
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. O
PUBLIC SEWER
P.C.NO. U
SEPTIC FANKSEEPAGE PIT OR JOB NO.
PITS ANDD/OR/OR DRAINFIELD @ CO.IMP.NO. W
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM
it CONNECT ADDITIONAL BLDG.OR R.NO,AFFIDAVIT WAIYIII 1A51M1NT RECORD.INSTDATE
WORK TO HOUSE SEWER @ - - a:
OVERFLOW SEEPAGE PIT.DRAINFIELD Q
EXTN..CESSPOOL.DRYWELL,MANHOLE @ W
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL r 't
Y
OWNERS PERMIT E CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP.PITS)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE D ISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTrP TO DISCONNECT PLUG AND
RESIDE IN, THE AB• OV E' DESCRIBED RESIDENTI'A�L PROPER Y
�� ABANDON HOUSE SEWER
SIGNATURE .rf' BACKFILL SEPTIC TANKS 11LOF PERMITTEE ❑
SEEP.PIT(5) ❑ CESSPOOLS
VALIDATION
CK. M.O. CASH
7y
, 4/72
76A642L APPLICATgN FOR P MIT
76 A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. t ( !c
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK RACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
US E OFIGS DISTRICT NO. GBK PG
ROUP MAP SED
BILDNBY
i
CONTRACTORIt iYVA �GI� /- /
ADDRESS )(- CONNECTION DATA
CITY TEL. NO. STATION r�) DEPTH
LICENSE NO. CLAS STATE' -LIt: 5 C MANHOLE REFERENCE (f•1 /
Vv R
NO. DES RIP ION O WORK FEE TYPE OF CONNECTIO N LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER }
SEPTIC TANK.SEEPAGE PIT OR / P.C.NO.
PITS AND/OR DRAINFIELD @ CO.IMP.NO. JOB NO. O
HOUSE SEWER CONNECTING TO (,f
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR. 0
NO. DATE
WORK TO HOUSE SEWER a O O
OVERFLOW SEEPAGE PIT.DRAINFIELD u
EXTN..CESSPOOL.DRYWELL.MANHOLE @ W
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING a
y.
SEWER OR DISPOSAL SYSTEM � STATE ENCROACHMENT V)
L
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERCHARGES
S PERMIT s O O
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE d
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS_DAY OF 19_
OWNER OR \ NEW HOUSE SEWER
OWNERS AGENT -
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK YAl`
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP.PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INT TO DI SCONNEC PLUG AND
RESIDE IN. THE A DESCRIBED RESIDENT FOLD RT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS Cl
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS
—VALIDATION
C' O. CASH RR
6 9 2 PFEB 14 1 J D 6.0 0 ,&:,
I