HomeMy Public PortalAbout4930 ARDEN DR_Sewer__ 3-E4
76A642D APPLICATION OR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
LAMBIE, County Engineer ABUILDING
JOHN A. DDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN [CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER"
/L MAIL
BLOCK TRACT / ADDRESS
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. -NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS --
y/ BK PG
CONTRACTOR J
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
STA MANHOLE REFERENCE UPPER
REGISTRATION NO. [1 COUNTY ,
NO. DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CU B P.L. M.L.TO P.L.
or
77]
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. }
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. JOB NO. 0-
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N O O
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN.'CESSPOOL,DRYWELL,MANHOLE 0 $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 0-
d
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT N
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE 4, CONNECTION CHARGE FEE
'I HAVE 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 19_
OWNER OR NEW HOUSE SEWER 7 4
OWNERS AGENT (t
CONNECT ADDITIONAL V
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
L
AND SEWERS. CESSPOOL ❑ DRYWELL ❑CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
S REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
OR THAT I AM THE LEGAL OWNER OF,-AND INTEND TO DISCONNECT PLUG AND
THE A DESC IBED RESIDENTIAL PROPERTY. gBANDON HOUSE SEWER
BACKFILL SEPTIC TANKSITTEE
EEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
LIQ 2 2 4 5 1 JUN 3 1 0 Q '7.0 O N