HomeMy Public PortalAbout10681 ARROWOOD ST_Sewer_5/22/1963_house sewer connection to public sewer C E 808 10-62 .r
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE D DISPOSAL
BUILDING AND SAFETY DIVISION BUILDINC
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY R
NEAREST
FOR APPLICANT FILL IN CRD55 5T
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK, T
RACTI ADDRESS _ I t
NO. OF BLOGS.
SIZE OF / NOW ON LOT CITY TEL. NO.
USE OF DISTRICAND. GR P MAP ZRESSED BY
BUILDINGS
/ J BK PG
CONTRACTOR 'f�r /�' ,/� / _ .---
ADDRESSCONNECTION A
ATA
CITY � TE f� ION
STATEUPPER
MANHOLE REFERENCE
REGISTRATION NO. �' /; `L ❑ COUNTY CL
NO. DESCRIPTION OF WORK FEE PE OF NN N LENGTH F M O
HOUSE SEWER CONNECTING TO Y. C. _L/ M.L.TO P.L. U
PUBLIC SEWER @ $5.00 J
SEPTIC TANK,SEEPAGE PIT OR / P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. /_3 JOB NO. I
{`O.
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. C'Y PRIVATE DISPOSAL SYSTEM @ $3.00f CONNECT ADDITIONAL BLDG.OR AFFIDAVIT W EN EASEMENT RECORD.INSTR.NO. d
WORK TO HOUSE SEWER @ $3.00 H
OVERFLOW SEEPAGE PIT,DRAINFIELD z
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
_ PERMIT NO.
INDUSTRIAL
WASTE APPRO L
OWNERS PERMIT $ 2 00 c
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED•CON- REIMBURSEMENT 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 j NEW HOUSE SEWER
OWNERS AGENT --fi//--Vy
CONNECT ADDITIONAL _
,BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(5)
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 ❑ DRYW ELL El
I HEREBY 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, THEABO DESCRIBED REBID ENTIA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE �� 9 E] ❑ "
SEEP,PITS) CESSPOOLS '
VALIDATION ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH