HomeMy Public PortalAbout5018 ARDEN DR_Sewer__ i
CEBOB 3-62 9 q�� APPLICATION FOR PERMIT
7BA642D `
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS gd✓ �� /it�G/•+�1 y
WILLIAM A. JENSEN, Sup't of Building J
LOCALITY /'l&,W /;
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. 14
LEGAL
DESCRIPTION LOT NO. I OWNER
/ MAIL ^O I 6 Al
BLOCK TRACT 5 ADDRESS 3
NO. OF BLDGS. 7 .j-0-
SIZE OF LOT NOW ON LOT CITY !/+N (,• .TEL. NO. G/ rd
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
EIK PG
CONTRACTORDO(/q Q 60� /3 v!, v,
ADDRESS O ,,- CONNECTION DATA
CITY �� / (' 1 TEL. NO. V.3-1 F STATI N DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ElCOUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION NGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L. ,L, 0.
PUBLIC SEWER @ $5.00
P.C.NO.CO.IMP.NO. NO. 80
SEPTIC TANK,SEEPAGE PIT OR JOB
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO /ROA P IT NO. //m
PRIVATE DISPOSAL SYSTEM @ $3.00 T
CONNECT ADDITIONAL L.G.BOR AFFIDAVITW IV R EASEMENT RECORD. I STR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL,DRYW ELL.MANHOLE @ $5.00
ALTER,R HOUSEHWY.OR ST.WIDENING
IB,
SEWER OR @
$3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROV
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE !tom P C ECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO 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
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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 INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIB RESI ENTIyIL ROPE RTY
r / P� ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE � BACKFILL SEPTIC TANKS ❑
SEEP.PITS) ElCESSPOOLS ❑
VALIDATION ROBERT A. WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK. -