HomeMy Public PortalAbout5213 ARDEN DR_Sewer__ -62
7CEBOB
6A642D APPLICATION FOR PERMIT
6A642 -
COUNTY OF LOS ANGELES SEWER-SEWAGE.DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS �� .y
WILLIAM A. JENSEN. Supt of Building
LOCALITY
� .. .. -..-. .... .. w-.. .:,- .....-.. NEAREST •
FOR APPLICANT TO FILL IN CRDSS ST. �
LEGAL 71
DESCRIPTION LOT NO.. �~ '"` OWNER
MAIL
BLOCK TRACT .. . '� L ADDRESS V
NO. OF BLDGS. - -
SIZE OF LOT NOW ON LOT / CITYs' �. TEL. NO.
USE OF '..:
BUILDINGS / AP DISTRICT NO. GROUP BK M
.�.. PROCESSED BY
PG
CONTRACTO
ADDRESS �/ ,,•,L '.. CC5NNECTIOI4 DATA
CITY TEL. N . STATION ' �j) 1 DEPTH
�... - STATE .MANHOLE REFERENCE PPERI
REGISTRATION NO.'S �Id ❑ COUNTY / OWER "NO. DESCRIPTION OF WORK FEE =E OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO / CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ '$5.00 �
SEPTIC TANK,-SEEPAGE PIT O R - P.C.NO.
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP.NO. - JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
A
PRIVATE DISPOSAL SYSTEM. @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE -
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD -
EXTN..CESSPOOL.DRYWELL.MAN HOLE @ $5.00
ALTER. EPAIR OR ABANDON HOUSE
HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 _ STATE ENCROACHMENT
_ PERMIT NO.
INDUSTRIAL
WASTE APPROVAL '
OWNERS PERMIT s 2 00 CHARGES
" AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA-MED CON- REIMBURS EMENTFEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. •APPROVALS DATE INSPECTOR'S SIGN'�:URE
SIGNED THIS DAY OF _ 79_
OWNER OR / / NEW HOUSE SEWER ' ,�+ �,-• .�
OWNERS AGENT_ -.C�/Y`�'"Q� CONNECT ADDITIONAL .01
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S),
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION i 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 ❑ ORYWELL: ❑
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 T LEGAL OWNER OF, AND.INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE BED RESIDENTIAL PROP TY. ABANDON HOUSE SEWER
SIGNATURE -- / BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE s
SEEP,PIT(S) CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
L;10 9 1 6 9'G` JAN, 7 1 0 D 7.0.0M
L �