HomeMy Public PortalAbout4903 ARDSLEY DR_Sewer__ f
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76A642D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE 031SP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS NSS/E
WILLIAM A. JENSEN, Supt of BuildingLOCALITYNEARESTFOR APPLICANT TO FILL INCRD$B ST.LEGALyy /�'f'�/� w /DESCRIPTION LOT NO. a� OWNER A-� a r WVMAIL �.jBLOCK TRACT � ADDRESS_ / D/ NO. OF BLDGS. ` /I, o{SIZE OF LOT(/ NOW ON LOT / CITY ,e I0 TEL. NO. �--QUSE OF IBUILDINGSDISTRICTN GROUP MAP
BK PG
CONTRACTOR Ow ii er el-lc_
ADDRESS A� pI, j/ S�� 161-1
CONNECTION DATA
CITY b `/ L. NO. ? STATION DEPTH
MANHOLE REFERENCE UPPER
REGISTRATION ❑ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. a
PUBLIC SEWER C $5.00
SEPTIC TANK,SEEPAGE PIT OR P C.N°. O
CO.IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM e° $3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE (—
WORK TO HOUSE SEWER Q $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD UJI
E .,CESSPOOL,DRYWELL,MA NH OLE @ $5.00
ALTE REPAIR OR ABANDON HOUSE
HWY.OR ST.WIDENING h
SEWE OR DISPOSAL SYST M @ 83.0 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
L WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'IHAVE 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 SIGNATURE
SIGNED THIS DAY OF _19—
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
/
SEPTIC TANK,SEEP,PIT(S)
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ r
I /
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUI D BY LOS AN LES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH I AM THE LEG OWNER OF. AND INTEND TO DISCONNECT PLUG AND I
RESIDE IN, THE A V DESCRIBED SI E AL PROPERTY.
� ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE �"�`-' ' M''� BACKFILL SEPTIC TANKS ElT
SEEP,PIS) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
. 0 4 4 7'1100 KiliR 14 1 0 D 5,0 QN