HomeMy Public PortalAbout10501 LYNROSE ST_Sewer__ -6i
76A6423-61
APPLICATION FOR PERMIT
76A 842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING o �V �!L ]
JOHN A, LAMBIE, County Engineer ADDRESS V 1WILLIAM A. JENSEN, Supt of Building LOCALITY
Am
NEAREST /FOR AP LICANT TO FILL INCRoss sr. L
LEGAL / OWNER
DESCRIPTION LOT N0.
BLOCK TRACT / NAIL
6 SS' ADDRESS
)NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF
BUILDINGS DISTRICT NO. GROUP NAP P ESSED BY
BK PG
CONTRACTOR b e s /) dTif"C
ADDRESS 3 CONNECTION DATA
CITY TEL.NO.C V STATION I DEPTH )
REGISTRATION N0. ZS' ? STATE MANHOLE REFERENCE / UPPER r
COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO .� I
PUBLIC SEWER @ $ .00 / TYPE OF CONNECTI LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB L M.L.TO P.L.
PITS AND/OR DRAINFIELD @ s .00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN. CESSPOOL DRYWELL S .00 CL
P.C.N0. O
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ si 00 CO IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER 00 TRUNK PERMIT N0. ROAD PERMIT N0. a'
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM @ .00 PERMIT NO. U
INDUSTRIAL Lll
O_
WASTE APPROVAL N
CHARGES ?
OWNERS PMM $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DTE INSPECTOR'S SIGNA'6URE
TO THE PUBLIC SEWER. ;"
SIGNED THIS DAY OR 8- NEW HOUSE SEWER
OWNER OR M CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBYACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE ,THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDENTIA PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(S CESSPOOLS
OF PERMITTE
CA MATION ROBERT A. WOOD
CIL U.O. CASH SUPERVISING MECHANICAL HNGINEER
2 0 4 1 '0 HAY
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