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HomeMy Public PortalAbout4936 ARDEN DR_Sewer__ 3-64 76A642D APPLICATION FOR PERMI 6A64 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST ILDING JOHN A. LAMBIE, County Engineer DRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY FOR APPLICANT TO FILL IN DBS 5T. LEGAL DESCRIPTION LOT NO. 7 OWNER MAIL BLOCK TRACT a14- --1 ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. -NO. USE OF DISTRICT NO. GROUP MAP BUILDINGS PROCESSED BY / BK PG CONTRACTOR ADDRESS CONNECTION DpATA T ION D TW CITY EL. NO. v 7 -3STATE UPPER REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE ba4mgAa- NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONN LENGTH FROM HOUSE SEWER CONNECTING TO Y. C B.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 P.C.NO. SEPTIC TANK,SEEPAGE PIT OR JOB NO. �^ PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N �7 V PRIVATE DISPOSAL SYSTEM @ $3.00 {� CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. bATE O WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFI D EXTN.,CESSPOOL,DRYWELL, NH @ $5.00 V ALTER.REPAIR OR ABANDO HO HWY. OR ST. I LU SEWER OR DISPOSAL SYS @ $3.00 STATE ENCROACHMENT PERMIT NO. .a INDUSTRIAL OWNERS PERMIT $ WASTE APPROVAL CHARGES AUTHORIZATION TOTAL FEE 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 OF0e 1 19_ OWNER ORNEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK 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 PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY 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 M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN. THE ABO SCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE ILL SEPTIC TANKS ❑ OF PERMITTEE (S) ❑ CESSPOOLS ❑ ALIDATfb ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH LA Go 2 2 5 0;Q JUN 3 1 1 D 25.00- v CE60e 3-64 - 7eAe420 APPLICAT ON FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. 492 LEGAL DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT ADDRESS NZ5. OF BLDGS. SIZE OF LOT A NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY 1 /BK PG CONTRACTOR , ADDRESS ' cJJ CON^NCECTION DATA CITY CITY TEL, NO, TION (eq, ❑ STATE MANHOLE REFERENCE UPPER REGISTRATION NO. ® ❑ COUNTY NO. DESCRIPTION OF WORK FEE TYPE OF CONNEC LENGTH FROM HOUSE SEWER CONNECTING TO Y. C B P.L. M.L.TO P.L. / PUBLIC SEWER @ $5.00 4(/ r P.C.NO. SEPTIC TANK,SEEPAGE PIT OR NJOB NO. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ©� U PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 O OVERFLOW SEEPAGE PIT.DRAINFIELD V EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 Y.1 ALTER.REPAIR OR ABANDON HOUSE HWY. H SEWER OR DISPOSAL SYSTEM @ $3.00 STATE E ROACHMENT 6. PERMIT NO. y INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT S z o0 CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE 'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ .�" OWNER OR NEW HOUSE SEWER (]¢r� U OWNERS AGENT CONNECT ADDITIONAL d v BU ILDI'NG 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 PLUMBING AND SEWERS. CESSPOOL ❑' DRYWELL ❑ I HEREBY CERTIFY THAT 1 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 M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG'AND RESIDE IN, THE AB E ESCRI D RESIDENTIAL PR 5-91ABANDON HOUSE SEWER SIGNATURE KFILL SEPTIC TANKS ElOF PERMITTEE P,PIT IS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK. M.O. ^ CASH 2249IS-1JUN 310D 7.0ONN, ,4