HomeMy Public PortalAbout10507 LYNROSE ST_Sewer__ (2) -61
76A6423-61
APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FA
UILDING J S o A/Ra S
DDRESS
JOHN A, LAMBIE. Countp EagineerWILLIAM A. JENSEN, Supt of Building CALITYNEAREST
FOR APPLICANT TO FILL INOSS ST. JY�
LEGAL OWNER Q ,Q
DESCRIPTION LOT N0. �7 rr
BLOCK TRACT ,ii 6 �J MAIL
ADDRESS
NO.OF BLDGS. J
SIZE OF LOT NOW ON LOT ( f
Y TEL. NO.
USE OF
DI ICT NO. GROUP MAP PROCESSED BY
BUILDINGS ! /�/2�
BK PG `
CONTRACTOR ESSYADDRESS CONNECTION DATACITY -y : TEL. 0.� TION - DEPTH
SHOLE REFERENCE UPPER
REGISTRATION NO. SSS CNo. DESCRIPTION OF RK FEE
HOUSE SEWER CONNECTING TOPUBLIC SEWER @ S .00TYPE OF CONNECTIO (� LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ S .00 CURB P.C� M.L.TO P.L. 3
OVERFLOW SEEPAGE PIT,DRAINFIELD 1'
EXTN..CESSPOOL.DRYWELL @ $100 0-
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $100 CO.IMP. NO. JOB NO. + V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER S1.00
ALTER,REPAIR O R ABANDON SYSTEM HOUSE @ $ 00 STATE ENCROACHMENT SEWO
PERMIT N0. V
INDUSTRIAL w
WASTE APPROVAL N
CHARGES Z
OWNERS PERMIT E 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 APPROVAIrS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER 'z- CONNECT ADDITIONAL
OWNERSAGENT
AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE 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 SYSTEN
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEalA PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S ❑ CESSPOOLS
OF PERMITTEE
VALIDATION ROBERT A. WOOD
CK.
11.0. CAM SUPERVISING MECHANICAL ENGINEER