HomeMy Public PortalAbout10685 ARROWOOD ST_Sewer_6/28/1963_house sewer connection to public sewer -62
76A642APPLICATION FOR PERMIT
6A642D COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
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 `ROSS ST
LEGAL
DESCRIPTION LOT ) OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF SLD Gji.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP p�ROF ESSED BY
BUILDINGS BK PG /� //
CONTRACT 0 : f
f- '7G V q 4 3 I -'L
ADDRESS ,�� CONNECTION DATA
CITY TELA 4 STATION �. C' G, v DEPTH
4`1
TATE MANHOLE REFERENCE
O •�
REGISTRATION NO. ❑ COUNTY - s •L WEIR
NO. DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM J
HOUSE SEWER CONNECTING TO _J Y. CURB` P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO. O
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT N ROAD PERMIT O
A
PRIVTE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIv R EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSEHWY. OR ST.WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE �}!n ONNECTION CHARGE FEE q
i �..
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIB EXISTING D L G
TO THE PUBLIC SEWER. VALS DATE INSPECTOR'S SIG UR[=
SIGNED THIS DA OF 1
OWNER OR N HOUSE SEWER
OWNERS AGENT_
CO ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLESCOUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT [ THE LEGAL OWNER OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB ESCRIBEOXNTiAL OPER ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MiTTEE SEEP,PITS) E] CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK. M.OCASH SUPERVISING MECHANICAL ENGINEER
.
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