HomeMy Public PortalAbout4904 ARDSLEY DR_Sewer__ CE606 3-64;. A PPLOC A TION FOR I�ERMOT
76A64Zp COUNTY OFP`LOS
tltl�-ANGELES Itl Ir tl�( rSIGE,IfWCIVEIRE-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS _
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WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST L�
FOR APPLICANT TO FILL IN GROSS ST.
11—
LEGAL
DESCRIPTION LOT NO. OWNER
9 ' / MAIL
BLOCK � TRACT !/ /N L ADDRESS
NO. OF BL0GS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MA @ PD BY
BUILD,
ROC SE
NGS .,•„�� p ,.,,.,V
CONTRACTO G , leg
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ADDRESS7(2 Q 'y CONNECTION DATA
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CITY STATION DEPTH
tI /� TEL. NO. ,
/j •STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. / d'�(/� El COUNTY- LOWER
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 TAND/NK,SEEPAGE PIT OR P CB O
PITS AOR DRAINFIELD @ 810.00 CO.IMP. NO. JONO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVE EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 _ O
OVERFLOW SEEPAGE PIT,DRAINFIELD - U
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00l LU
ALTER,R"a-"'�^� ON HOUSE HWY. OR ST. E IN
SEWER O "9 @ $3.00 l - N
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
OWNERS PERMIT $ z 00 WASTE APPROVAL
CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
A HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSE 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 CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I 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 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNT AND STATE OF SEWA.'0£-Lj SPO2A SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNE NO INTEND TO u- v
DISCONNECT PLUG AND (/
1,EGNAT.IDE IN, THE ABOVE CRI D RESIDENTIAOPERTY. . ABANDON HOUSE SEWER
RE BACKFILL SEPTIC TANKS ❑
F PERMITTEE SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATIOC ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
r_,1 ' 6 9 a�� SEP17 1 0 5-00-