HomeMy Public PortalAbout10506 LYNROSE ST_Sewer__ -6,
76A6423-61
AP LICA`TION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU RES G l a s o 6 o
JOHN A, LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER I'G'e'e' ..Q R
DESCRIPTION LOT N0.
BLOCK TRACT a 6 S 5-!/ MAIL
ADDRESS
NO.OF BLDGS. i
SIZE OF LOT NOW ON LOT ( CITY TEL NO
USE OF 17_9�w 11
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG �S
CONTRACTOR �<d S ... A
ADDRESS CONNECTION DATA
CITY TEL. �' S STATION DEPTH
❑ STATE MANHOLE REFERENCE
COUNTY UPPER
REGISTRATION N0. ❑'
NO. I DESCRIPTrON OF WORK FEE
HOUSE SEWER CONNECTING TO _
PUBLIC SEWER @ S .00 _ - TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S .00
OVERFLOW SEEPAGE PIT,DRAINFIELD >_
EXTN. CESSPOOL DRYWELL @ $1.00 d
HOUSE SEWER CONNECTING TO P.C.N0. O
PRIVATE DISPOSAL SYSTEM @ S1.00 CO IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER ca $100 TRUNK PERMIT NO. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT U
SEWER OR DISPOSAL SYSTEM @ JI.00 PERMIT NO
INDUSTRIAL W
DIN APPROVAL a
N
'�i�f�wt�i+ CHARGES Z
O.l�MR'S PERT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROV= DITE INSPECMR'S SI N�ITURE
TO THE PUBLIC SEWER. `off
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR w f CONNECT ADDITIONAL °•
OWNERS AGENT _ .V BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYrABANDO
L ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGEPAIR,SEWER OR
PLUMBING AND SEWERS. DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFN DISCONNECT
HOUSE D
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVEL SEPTIC TANKS ❑
DESCRIBED RESIDENTI L P OPERTY. LSIT ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE
/-VALIDATIOIII ROBERT A.A WOOD
M.0. CABM SUPERVISING MECHANICAL ENGINEER
0LD