HomeMy Public PortalAbout10516 LYNROSE ST_Sewer__ -61
76A6423-61
APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Enqineer ADDRESS N
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST A
FOR APPLICANT TO FILL IN CROSS ST. /7
LEGAL / L OWNER M e elle
DESCRIPTION LOT NO.
BLOCK TRACT a MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE DI ammgmkoiEr
DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
' CONTRACTOR Q � � I _ �BK Pg
ADDRESS -Y CONNECTION DATA
CITY TEL. 0.� Cr $S STATION DEPTH
CO ® STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. O COUNTY e�nwG�
NO. DESCRIPTION OF R FEE
HOUSE SEWER CONNECTING TO
1 PUBLIC SEWER @ $2.00 S TYPE OF CONNECTIO LENGTH FROM
SEPTIC TgNK,SEEPAGE PIT OR Y. CURB L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S .00
OVERFLOW SEEPAGEPIT,DRAINFIELD -
ETN CESSPOOL DRYWELL S 1.00 d
HOUSE SEWER CONNECTING TO P.C.NO. - O
PRIVATE DISPOSAL SYSTEM @ $ .00 ; CO IMP. NO JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. w
WORK TO HOUSE SEWER S 00 O
SEWER'O,DISPOSAL SYSTEM HOUSE @ $ 00 STATE ENCROACHMENT `
PERMIT NO U
_ INDUSTRIAL W
Y WASTE APPROVAL N
trppr�t�� r CHARGES Z
O'���V•m-s PmmT S ?1 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 APPROVALS TES INSPECTORjS SIGJIVVRE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR ll__A.� CONNECT ADDITIONAL '`�
OWNERS AGENT 1 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 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 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 AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI LP OPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S ❑ CESSPOOLS
OF PERMITTEE
AMATION ROBERT A. WOOD
cd M.o. c"H SUPERVISING MECHANICAL ENGINEER