HomeMy Public PortalAbout10681 ARROWOOD ST_Sewer_5/22/1963_manhole 7e a Zo 82 APPO_OCATION FOR rRM IT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION4' NEAR
ING
JOHN A. LAMBIE, County EngineerESS
WILLIAM A. JENSEN, Sup't of Building
ITV FOR APPLICANT TO FILL IN sr.
LEGAL Har
DESCRIPTION LOT NO. OWNER [ � V
MAIL
BLOCK TRACT 1 ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO.
BUILDINGS GROUP MAP ^PROCESSED BY
- I
K
CONTRACTOR
ADDRES /,,"� ✓ _ /// CONNNEEECTION DATA
CITY S- (� TEL. S ON ,( H
�` ❑ COUNTY E? STATE MANHOLE REFERENCE �J UPPER
REGISTRATION NO.
NO. DESCRIPTION OF WORK FEE T E OF C NE O LENGTH F MCL
HOUSE SEWER CONNECTING TO Y. U L. M.L.TO P. O
O. JOB NO.
PUBLIC SEWER _ @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. (J
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. N09
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. .(/ S
PRIVATE DISPOSAL SYSTEM @ $3.00 m/ �✓+ O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE luL
WORK TO HOUSE SEWER @ $3.00 LU
OVERFLOW SEEPAGE PIT.DRAINFIELD N
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL YS Em @ $3.00 STATE ENCROACHMENT
` PERMIT NO.
�•J INDUSTRIAL
WASTE APPRO VA
OWNERS PERMIT 223m
AUTHORIZATION TOTAL FEE ` /s
CONNECTION CHARGE 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,
ALS• DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ `
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 DRAINFIELD A
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑ pet
'
1 HEREBY CERTIF I AM PROPERLY REGI TE ED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RE I D Y LOS ANGLES COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM .
CALIFORNIA OR I M THE LEGAL O R O , A INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A V DESCRIBED R21TIA PR P RT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PER MITTE SEEP,PIT(S) ❑ CESSPOOLS E3
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. ASH
Lt';l�U 5 0 x 5 1'i,,"y F'f 1. 1 D 2 5.t i L�' 17
• � V