HomeMy Public PortalAbout5201 ARDEN DR_Sewer__ 76A6 23D-62 APPLICATION FOR PERMIT s
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS 2e01
WILLIAM A..JENSEN, Sup't of Building.
LOCALITY G
NEAREST
FOR APPLICAN TO FILL IN CRD55 ST.
LEGAL
DESCRIPTION LOT NO. OWNER
" �.� S.n / /� !' `i /�• �;.. G�./�'
BLOCK TRACT ` .1 / MAILADDRESS +�
NO. OF BLDGS. �^
SIZE OF LOT NOW ON LOT CITY / TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP - r•-�K MAP PG PROCE D BY
CONTRACTOR ✓ �.�.. C5,
ADDRESS / ffllll C�-O�NNNECTION DUATA '
/L.
CITY TEL. N f/„y STATION6 J DEPTHEl /D
STATE MANHOLE REFERENCE
REGISTRATION NO. ���{/ ❑ COUNTY W, LOWER
NO: DESCRIPTION OF WORK FEE - TYPE OF CONNE }IO NGT FROM
HOUSE SEWER CONNECTING TO Y. CURB L. .L.TO P.L.
PUBLIC SEWER @ $5.00 -
SEPTIC TANK,SEEPAGE PIT OR .C.NO.
>� ^ CJI
PITS AND OR.DRAINFIELD @ $10.00 C4a_LA68- J0B"NlT w/ CJJS
HOUSE SEWER CONNECTING TO TRUNK* RMIT NO. ROAD PERMIT NO. �.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVERfASIUIENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00' '
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE - HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT "
PERMIT NO. -•-
.. INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00
N CHARGES
' CONNECTIOCHARGE FEE -
AUTHOMATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON. REIMBURSEMENT FEE
TRACTOR TO 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_ t/4 CONNECT ADDITIONAL v
ADDRESS -
BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I .HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 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 Y LOS ANGLES DUN
TY A D STATE OF - SEWAGE DISPOSAL SYSTEM'
CALIFORNIA' OR THAT A THE LEGAL ER OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE E DESCRIBED R TIALPERT Y. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS El
PER Mt'ETEE SEEP.PITS) ❑ CESSPOOLS ❑ -
VALIDATIO ROBERT.A. WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
- - _
01 3 3 17
4 _ _