HomeMy Public PortalAbout5135 ARDEN DR_Sewer__ 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRGSS ST.
LEGAL
DESCRIPTION LOT NO. ./� � OWNER
MAIL
BLOCK TRACT IYYtl S ��0 4 ADDRESS
SIZE OF LOT NOW OON LOTS CITY 7-L TEL. NO.
USE OF DISTRICT NO. GROUP MAP ROC SS D BY
BUILDINGS �gJ� ABK PS
CONTRACTOR ?j �j^��I �•� I / ',
ADDRESS an �s CONNECTION DATA
CITY TEL. NO. / �� STATION 6 E T ! a a DEPTH *7 �y
STATE Lic
LICENSE NO,; .6'3�0 GLASS MAN LE REF2�NC€_I yL/ �
C/ LOWER
NO. DESCRIPTION OF WORK FEEYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EAS[MCRT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 a
OVERFLOW SEEPAGE PIT.DRAINFIELD 0
EXTN..CESSPOOL.DRYWELL, @ $5.00 C>
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT C:)
MANHOLE PERMIT NO. C~.7
!� $7.00
INDUSTRIAL yJc-
WASTE APPROVAL v)
OWNERCHARGESS PERMIT a
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE 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_ op
OWNER OR NEW HOUSE SEWER '��
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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 REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF Ca
N IA OR THAT 1 AM THE GAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV /CRI D RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE (/�fy�/ ❑
OF PERMfTTEE BACKFILL SEPT ANK
T}� SEEP.PIT(S) ESS OOLS ❑
VALIDATION CK.. M.O. CASH
0 3 6-r_5C 29 1 1 5.0 0