HomeMy Public PortalAbout4826 ARDEN DR_Sewer__ GA642 D 082
7APPLICATION F R PERMIT
78 A 842
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING n
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSS 5T
LEGAL
DESCRIPTION LOT NO OWNER
/�/p
MAIL
BLOCK TRACT `5-V ADDRES
A/ "NO OF BLOGS
SIZE OF LOT4 /1t*�OW ON LOT 3 TEL NO
USE OIF DISTRIG O GROUP MAP PROCESS
BUILDNGS ED BY
� PG
CONTRACTOR
ADDRESS CONNECTION
DEPTH
CITY TEL NO STATIONry
I�-I{ STATE MANHOLE REFERENCE _ U UPPER
REGISTRATION NO IJ COUNTY �.�C bI pu uLOWER
NO DESCRIPTION OF WORK FEETYP O CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y U P L ML TO P L v
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P C NO U
PITS AND/OR DRAINFIELD @ $1000 1 O .108 NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT N ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INST O DATE
WORK TO HOUSE SEWER @ $3 0o
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE '-�
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPR L
OWNER$ PERMIT $ z o0 CHARGES
AUTHORIZATION TOTAL FEE COECTION CHARGE FEE 1
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 G
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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 ❑ DRYWELL Cl
I HEREBY CERTIFY THAT I AM PROPER REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM TH ER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN T E CRIB D R TIAL PROPERTY gBAN DON HOUSE SEWER
SIGNATUR ❑
OF PERM I BACKFILL SEPTIC TANKS
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATIOU ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O GASH
L,`Lo 7 1 8 DEC 31 1 0 D 5.0 0