HomeMy Public PortalAbout10533 LYNROSE ST_Sewer__ 6A642 D-sI
fiA[i42APPLICATION FOR PERMIT
'
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING y^
JOHN A, LAMBIE, County Eaginesa ADDRESS � �
WILLIAM A. JENSEN, Supt of Building ,-
LOCALITYI NEAREST
FOR APPLICANT TO FILL IN
CROSS ST. �'r
LEGAL
DESCRIPTIOtT LOT NO. OWNER : `
BLOCK TRACT , ' MAIL
.rlr �`� ADDRESS
NO.OF SLOGS,
SIZE OF LOT NOW ON LOT rDISTRICT
TEL. NO.
USEOF
DI GROUP MAP Pi�OCESSED BY
BUILC9ING5 r..3-�;� 8K P6
CONTRACTOR �� p',: ? .�,✓ ..;l
ADDRESS / CONNECTION DATA
CITY . 7E N0. STATION 4 DEPTH
r+� E STATE MANHOLE REFERENCE
REGISTRATION NO [] COUNTY LDWER
NO. 1 DESCRIPTION OF WORK.' FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $9.00 ) '" .' TYPE OF CONNECTION LENGTH FROM t 'c"
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L, ML.TO P.L. 6 ?
PITS AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINI=IELD y.
EXTN..CESSPOOL.-DRYWELL $2 OO p,
HOUSE SEWER CONNECTING TO P,C,No.
PRIVATE DISPOSAL SYSTEM @ $1100 CO.IMP. NQ. JOB N0, Q
CONNECT ADDITIONAL BLDG,OR I
WORK TO HOUSE SEWER TRUNK PERMIT N0. ROAD PERMIT N0,
4100
ALTER,REPAIR OR ABANDON fIOUSE V O
SEWER OR DISPOSAL SYSYEM CW 511.0@ STATE ENCI20ACHMEN7
dERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWMWS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION r TOTAL. FEE VZ' �.��..:" REIMBURSEMENT FEE.
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ETD CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNAT,UftE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF-19-- 19- NEW HOUSE SEWER
OWNER OR
i h_ _; CONNECT ADDITIONAL
OWNERS AGENT- 'Vr_� BUILDING OR WORK
ADDRESS SEPTIC TANK;SEEP.PITS)
AND/OR DRAINFIELD
I 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 R ALTER,REPAIR,SEWEEOR
PLUMBING AND SEWERS, SEWAGE DISPOSAL
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/Oft DISCONNECT PLUG AND
EM-
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTLAL .ROPERTY. {. -"' BACKFILL SEPTIC TANI(s 0
SIGNATURE
SEEP.PIT(5) C] CESSPOOLS
OF PERMITTEE - '✓`lam :
VALIDATION ROBERT A. WOOD
i CIS. U.o. CASH SUPERVISING MECHANICAL,ENGINEER
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