HomeMy Public PortalAbout10521 LYNROSE ST_Sewer__ / r
C
64
21D6,
6A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS 1 �
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAR T
OR APPLICANT TO FILL IN
CROSS ST.
LEGAL -17
DESCRIPTION LOT N0. r' OWNER -
BLOCK TRACT # MAIL
ADDRESS
NO.OF BL GS.
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF >
BUILDINGS ° DISTRICT NO. GROUP MAP PROCISSED BY
BK PG
CONTRACTOR ,�. ) t �
7'. _ syr 1
ADDRESS g ;��. ;-L:'1 '�,v, CONNECTION DATA
CITY '''�:. - �..., .. ' TEL-. 0. CLT_ .a STATION �° rkw;
DEPTH
✓ �t STATE MANHOLE REFERENCE IfPPE(t\
REGISTRATION NO. ! (] COUNTY ' ti-gip7 LOWER
NO. I DESCRIPTIONN OF FEE
HOUSE SEWER CONNECTING TO rr
PUBLIC SEWER $ .00 L TYPE OF CONNECTIO LENGTH FROM "
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L;, M.L.TO P.L. sl
PITS AND/OR DRAINFIL•LD
OVERFLOW SEEPAGE PIT,DRA[NFLELD >_
EXTN..CESSPOOL.DRYWELL @ E.00 Ib
HOUSE
SEWER
SYSTEM TO @ 1.00 CO.IMP.NO. OB NO. f
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. ix
WORK TO HOUSE SEWER 1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT - O_
SEWER OR DISPOSAL SYSTEM G) 1.00 PERMIT NO. U
INDUSTRIAL a
WASTE APPROVAI. V)
CHARGES z
T7
OWNEWS, PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL Fes. L REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAkED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19— NEW HOUSE SEWER _
OWNER OR ` ��,.. :' CONNECT ADDITIONAL
�.
OWNERS AGENT BUILDING OR WORK
ADDRESS C TANK,SEEP.PITS)
'SEPT.Np/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 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 OP THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE:NTIA PROPERTY. BACKFILLS£PTiC TANKS ❑
SIGNATURE SEEP.PITS' CESSPOOLS
.GSL 1 A ti'w w
OF PERMITTEE.-
VALIDATION ROBERT A. WOOD
`'CR. ;' X.O. CA3R SUPERVISING MECHANICAL ENGINEER