HomeMy Public PortalAbout10527 LYNROSE ST_Sewer__ ' s P
'E808 6421D6,
'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 a —
WILLIAM A. JENSEN. Sup't oI uildinq LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL %r _ , t
DESCRIPTION LOT NO. A3 OWNER "L-C- 'J*•--'�s> ' y, h:.= 1 ::,3,y.. •,,_i-b.
BLOCK TRACT --
r5: MAIL
°eJ.-.3- ADDRESS
NO.OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS x -` DISTRICT NO.I GROUP MAP ;PROCESSED BY
CONTRACTOR
BK Pe_ j !.
r
ADDRESS ti, 's x- w. `` CONNECTION DATA
CITY ,-'' � 1 h_ TEL.WD. S t ° --Z, STATION DEPTH
1
REGISTRATION NO. d = COUNTY MANHOLE REFERENCE
� _ LOWER
No. DESCRIPTION O WORK FEE
HOUSE SEWER CONNECTING TO — --
PUBLIC SEWER @ S .00 TYPE OF CONNECTION--- LENGTH FROM
PIETS AND/OR DRAIN FIELDPTIC TANK,SEEPAGET OR @a O® Y. CURB P.L'. M.L.TO P.L. r
OVERFLOW SEEPAGE PIT,DRAINFIELD � �.
EXTN..CESSPOOL.DRYWELL @ S .00
HOUSE SEWER CONNECTING TO P.C.ND. 'fi""
PRIVATE DISPOSAL:SYSTEM @ $.00 CO.IMP. NO. JOB NO. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. t
WORK TO HOUSE SEWER $.00.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM PERMIT N0. V
INDUSTRIAL LL!
WASTE APPROVAL
CHARGES z
OWNER'S PER 1" S 2 00 CONNECTION CHARGE FEE —
AUTHORIZATION TOTAL FEE !7 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY 0 NEW HOUSE SEWER
OWNER OR r CONNECT ADDITIONAL
OWNERS AGENT ' °- x BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
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 Ij
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 S ENT PRM SHE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS
DESCRIBED OR PROPERTY. D
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERNITTE
VALIDATION ROBERT A. WOOD
cr- Y.o. CASH SUPERVISING MECHANICAL.ENGINEER