HomeMy Public PortalAbout10507 LYNROSE ST_Sewer__ CE808 3\61
76A6421) APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION ADDRESSG a 5 0 N 1Q0 S '
IOHN A, LAMBIE. County Engineer
WILLIAM A. IENSEN. Supt of Building LOCALITY T
NIZE&MmomNEAREST l
FOR APPLICANT TO FILL IN CROSS sT. A L.
LEGAL
DESCRIPTION LOT N0. Q OWNER
BLOCK TRACTq S"S' ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT N0. GROUP MAP CESSED BY
QNB � d 17 TEL
PG. L
CONTRACTOR _/lna,_/
ADDRESS CONNECTION DATA
CITY J7 JLto,,,6L
TEL STATION DEPTH
STATE
REGISTRATION N0. p L OUNTY MANHOLE REFERENCE , _ /l UPPER
NO. I DESCRIPTION OF,WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 00 TYPE OF CONNECTIO LENGTH FROM 7
SEPTIC TANK,SEEPAGE PIT OR Y. CURB L. M.L.TO P.L. c
ITS AND/OR DRAINFIELD @ $3 100 ��
OVERFLOW SEEPAGE PIT,DRAINFIELD a
EXTN CESSPOOL DRYWELL @ S 00 C
HOUSE SEWER CONNECTING TO P C.NO. O
PRIVATE DISPOSAL SYSTEM @ S1 00 - CO IMP. NO. JOB NO. r V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER st 00 GC
SEWER OR DIISPOSAL SYSTEN HOUSE @ S 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL to
CHARGES Z
OWNEWS PERMIT —$ 1 21 00 CONNECTION CHARGE FEE -
AUTHOMATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. � '
SIGNED THIS DAY OF- 19_ NEW HOUSE SEWERL/tn..-
OWNER OR CONNECT ADDITIONAL Y4
OWNERS AGENT BUILDING OR WORK
ADDRESS SSEPTIC ND/ORTANK,SEEP.PIT(S)
DRAI HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTE
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT
HOUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L OPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE,,,,,,,
VALIDATION ROBERT A. WOOD
cR H.0. CASH SUPERVISING MECHANICAL,ENGINEER
110 kL
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