HomeMy Public PortalAbout5010 ARDEN DR_Sewer__ =� DEPARTAUENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING / O � n NEAREST
ADDRESS CROSS ST.
LOCALITY �, DISTRICT NO. SERIAL NO. PERMIT NO.
� f
NEAREST � A /2Z C` /�`�
CROSS ST. p
p -
RECEIVED
BY Read y for naPasYion- DATE,ISSUED
OWNERMAIL
ADDRESS USE ZU OCCUPANCY BK MAP PG
CIT TEL.NO b I ® qyI �^
CONTRACTOR CO.IMP.NO.
ADDRESS - JOB.N0.
CITY ' � TELAO. TRUNK PERMIT NO.
s� � STATE �j
REGISTRATION NO. S �`� (=4 �'� RYA ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT / ���/ INDUSTRIAL
/ WASTE APPROVAL
SIZE OF LOT `�� NO.OF BLDGS.
NOW ON LOT CHARGES
USE
—BUILDINGS CONNECTION CHARGE FEE
I �
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO s�
PUBLIC SEWER @ $ 3.50 LAI) RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER- I.00 N0.
ALTER OR REPAIR EXISTING I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR i
PITS AND/OR DRAINFIELD 2.00 STATION J 1 �— 3� S DEPTH
CESSPOOL—DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 �J� MANHOLE REFEREC
U.I 17 LOWER
TYPE OF CONNECTION LENGTH FROM
CURB M.L.TO P.L.
OWNERS PERMIT � I I 00
AUTHORIZATION TOTAL FEE I ,? y
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
C0014TRACTOR TO CONNECT THE ABOVE ESCRIBED EXISTING ' APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS-------- -----.. AY OF...... ... ... .--.....190 NEW HOUSE SEWER
OWNER OR ��-/y�� - CONNECT ADDITIONAL v
OWNERS AGENT...... ..: ....../-.._!-.......-.-.---- -----.-. BUILD[NG OR WORK
v SEPTIC TANK,SEEP.PIT(S)
ADDRESS--.sS-..OI-O..--_ .Q..--.--. .-. - ,ti-.-L/i-�.�... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL[3 DRYWELL E
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS� �e
SIGNATURE �as�^ ��y SEEP.PIT(S)� CESSPOOLS IIS 4/Y c�Ci
OF PERMITTEE./v'-----------................... - -
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