HomeMy Public PortalAbout4922 ARDSLEY DR_Sewer__ CE808APPLICATION FOR EPERMIT76A642D PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
.. NEAREST
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. -(
S12E OF LOT NOW ON LOT CIT TEL. •NO..
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS y
CONTRACTOl�Y
ADDRESS - CONNECTION DATA
CITY TEL. NO. 11� STATIONS DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. El 'COUNTY. LOWER
NO. DESCRIPTION F WORK FFIf TYP CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 35.00 -PIG-me—
SEPTIC TANK,SEEPAGE PIT OR / CL
PITS AND/OR DRAINFIELD $10.00-. CO.IM NO. JOB NO. �1 d
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, V
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR,NO. DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
E SSPOOL,DRYWELL,MANHOLE @ $5,00 U
ALTE EPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 1CL
R OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT A, V Z
PERMIT NO. V
rl
INDUSTRIAL
WASTE APPROVAL I
bb
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS '
TO THE PUBLIC SEWER. DATE IN ECTORSIG ATURE
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A VE DES BED REST ENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE Y BACKFILL SEPTIC TANKS El
PERMIT ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
L&Oa FM23 1 0 D 5.0 ON