HomeMy Public PortalAbout5207 ARDEN DR_Sewer__ r
CEBOB -62
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDI . /
JOHN A. LAMBIE, County Engineer ADDRESS V N
WILLIAM A. JENSEN, Sup't of Building v_
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSS 5T.
LEGAL f
DESCRIPTION LOT NO. tTRT v OWNER
MAIL
BLOCK TRACT y '� ADDRE55� �� 77
f
NO. OF BLDG5.
SIZE OF LOT NOW ON LOT CITY (s, TEL. NO.
USE OF
BUILDINGS ' DISTRICT NO. GROUP MAP PROCESSED BY
T BK PG
CONTRACTOR , 'rte :-7), a � e? �L
ADDRESSY�J , CONNECC�TION ATA
CITY TEL. N STATION L.j/�/ S DEPTH
77
REGISTRATION NO. ��- ❑ COUNTY MANHOLE REFERENCE
STATE „ OWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO 'Y.� CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK.SEEPAGE PIT QR _ P.C.NO. r
Nr
PITS AND�OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. !!
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. jt/
eo
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECTADDITIONAL BLDG.OR AFFIDAVIT
WAIVER I EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ��pp
E XTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 �y
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING ��II
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z Oo CHARGES
AUTHORIZATION TOTAL FEE 7 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�IG,yTURE
SIGNED THIS DAY
OWNER OR NEW HOUSE SEWER i
OWNERS AGENT_ y CONNECT ADDITIONAL O/ -
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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 ANGLES COUNT A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A H LEGAL OWNER OF, A INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV ES' IBED RE SID IA P PERTY. ABANDON HOUSE SEWER
SIGNATURE f BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
EP,PIT(S) El CESSPOOLS
VALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
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