HomeMy Public PortalAbout10829 ARROWOOD ST_Sewer__ 9v'�-
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / Z �p
JOHN A. LAMBIE, County Engineer noDREss
WILLIAM A. JENSEN, Sup't of Building --
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
CROSS 5
LEGAL
DESCRIPTION LOT NO, OWNER
J( MAIL
BLOCK TRACT /� ADDRES
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY, TEL. -NO.
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USE OF •I DISTRICT N 1 PG
BK GROUP MAP PROCE D BY
BUILDINGS 4
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CONTRACTO 2
Y�
ADDRESS f C NNECTION DATA
CITY TE - STATION DEPTH
STATE M NH LE EF ENCE UP ER
REGISTRATION NO. ❑ COUNTY ER
NO. DESCRIPTION OF WORK FEE 4 TY E F CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. .CCRB P.L. M.L.TO P.L.
'PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.G.NO. �..
PITS AND/OR DRAINFIELD @° $10.00 CO.IMP. NO. JOB NO. a
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PER M7
O
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ S3.00 Q
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 W
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 N
STATE ENCROACHMENT
„�. PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH HE 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 O 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR . ALTER,REPAIR,SEWER OR
LICENSED AS REOU BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T 1 AM THE LEffALER OF AN INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE BO, DESCRIBEDTIA PR ERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITT SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
L (O2 0 1 7 HU26 1 0 D 5.0 0 `
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