HomeMy Public PortalAbout5208 ARDEN DR_Sewer__ �TEMPLE CIT
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COUNTY OF LOS ANGELES �����—�� ��Zi� ®OSP®SA� �~
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND .SAFETY DIVISION ,
BUILDING
JOHN A. LAMBIE, County Engweer ADDRESS•
' CASSATT D. GRIFFIN, Supt of Building
LOCALITY _P .Y1t�g._ '^•..__sem '
-nkkm - .NEAREST:
FOR'APPLICANT Tor FILL:IN CROSS ST.
FDEkRIPTION
L' LOT`N0. / OWNER. TRACT . - - ADDRESS . .{]5 Et ��(..- ��f. d.•NO.'O BLDGS.OT. L -�• 2 NOW ON LOT CITY. "7")-,;g./✓�f'd T,EL. N0,` '-*. f a
USE OF s
BUILDINGS - DISTRICT NO..'GROUP I IAP ' LFCESSED BYBKt`' PG
CONTRACTOR
ADDRESS Z ! - 'CON ECTIO DATA
CITY �. - t --. _ -
i1 '� . TEL:NO. �- STATION '.DEPTH_
f ❑ .STATE MANHOLE-REFERENCE _ UPPER• -
REGISTRATI6N�0. '- ❑" COUNTY o POWER, -
NO. DESCRIPTION OF WORK FEE.
e 'HOUSE SEWER CONNECTING TO
PUBLIC SEWER. @...$3.00 TYPt OF•CONNECTION
LENGTH FROM -
SEPTIC TANK,SEEPAGE PIT OR -Y.. CURB Pa. M.L.�TO:P.L.
PITS AND/OR DRAINFIELD @-$3.00
.OVERFLOW SEEPAGEPIT,DRAINFIELD
EXTN..CESSPOOL.`DRYWELL _ @ $2.00
HOUSE SEWER CONNECTING TO ' _.'. P.C.N0: .
' PRIVATEDISPOSAL SYSTEM' @ $1.00 CO.-IMP.'N0. JOB NO. -
CONNECT ADDITIONAL BLDG-.OR., `. d_70- -TRUNK PERMIT NO." ROAD PERMIT N0:
WORK'TO HOUSE SEWER @.$1.00 - f
ALTER,REPAIR OR-ABANDON HOUSE. - STATE ENCROACHMENT - -
" SEWER OR DISPOSAL SYSTEM i-' @.$1.00 PERMIT NO;
`INDUSTRIAL - - -
WASTE':APPROVAL
CHARGES . - -
OWNER'S PE MT: $ Z. :00 CONNECTION CHARGEFEE-
AUTHORIZATION TOTAL.FEE
_s REIMBURSEMENT FEE
1 HAVE".AT THIS DA•TEL A"CONTRACT WITH THE HEREIIN NAMED CON.
TRACTOR-70 CONNECT THE ABOVE DESCRIBED EXISTING 'DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE;•PUBLIC S _
SIGNED THIS DAY ' 19 NEW HOUSE SEWER ► f
OWNER'OR' . ,¢! CONNECT ADDITIONAL
OWNERS AGENT ¢`-� •+-*-��f°�� BUILDING DR WORK-'
' r SEPTIC'TANK,.SEEP,-PIT(S)
ADDRESS- ' �'i "' ( AND/OR.DRAINF,IELD
I.'HEREBY ACKNOWLEDGE THAT I HAVE READ THIS,.APPLICATION - - - • -.
AND STATE THAT JHE 'ABOVE IS CORRECT•.AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH-ALL ,COUNTY.ORDINANCES, ''AND'.STATE LAWS' REGULATING ' ALTER,REPAIR,SEWER OR '
PLUMBING AND SEWERS:" .' ' SEWAGE DISPOSAL,SYSTEM
I -HEREBY-..CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS -REQUIRE'D.'BY LOS.ANGELES COUNTY".AND STATE OF
CALIFORNIA..OR THAT I AM-TE ,LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RES I TIAL.PROPERY. BACKFILLSEPTIC TANKS'❑
- 9 SEEP.PIT(S),❑ CESSPOOLS ❑' "
SIGNATURE
OF."PERMITTEE
®" ✓" ALIDATIO " ROBERT A.-WOOD
CK:• M.o. CASH MECHANICAL ENGINEER
SUPERVISING M ANIC