HomeMy Public PortalAbout10539 LYNROSE ST_Sewer__ :ABAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING� ,tt,
JOHN A, LAMBIE, County Engineer ADDkESS E3Al
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FELL IN CROSS ST. L4. U, J
LEGAL OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT p CITY TEL. N0,
USE OF
DI r .y DISTRICT NO. GROUP MAP "OCESSED BY
BUILDINGS a.., �_ BK PG ''.
CONTRACTORL .
ADDRESS CONNECTION DATA
CITY 'f}t TEL'WO. _� < 5 STATION "-D A, DEPTH ., =
a 6
STATE MANHOLE REFERENCE UPPER "..
REGISTRATION N0. COUNTY ?lex! '�" - �'- "
No. I DESCRIPTION OF,WORK FEE —
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $4.00 `r € TYPE OF CONNECTION =« LENGTH FROM
SEPTIC TgqNK.SEEPAGE PIT OR Y. CURB �P M.L.TO P.L,
PITS ANDIOR DRAINFIELD
OVERFLOW SEEPAGE PIT,DAINFIELD
EXTN.,CESSPOOL.DRYWELL SZL00 J
PRIVATSE E DISPOSAL CONNECTING
1`0. @ SI)OO CO.IMP. NO. JOB NO. �' ��' ''�l- o
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO, ROAD PERMIT NO. 9x
WORK TO HOUSE SEWER S 00 O
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT F
SEWER OR DISPOSAL SYSTEM $1,00 PERMIT NO,
W
INDUSTRIAL CL
WASTE APPROVAL Z
■s
��+ CHARGES
OWNER'S PERMIT $ 2, OO CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE ANA�MED CON-
TRACTOR TO CIONNECT THE ABOVET EREIN DESCRIBED WITH THEIEXISTING DWELLING APPRC?VALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OP 19_____ NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT. IV BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 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 TEAT I AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDENT AL PROPERTY. I
.- SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
-VALIDATION ROBERT A.WOOD
cX. X.0. CASH SUPERVISING MECHANICAL INGINEER