HomeMy Public PortalAbout10553 LYNROSE ST_Sewer__ E806 3-61
6A642D APPLICATION FOR PERMIT
COVINTY OF LOS A._NlEVE_`i SEWER--SEWAGE DISPOSAL
DE-PARTMENT Or COUNTY ENC11NUM
BMLDIN� AND SAMY DIVISION
'OHN A, LAM _41
HIE' co nlr!Pqlnoo
WILLIAM A. 1ENSE-4 up B uu ding LOCAL ITY
N E A R.
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NOjjjloV OWNER
BLOCK TRACT FAIL
ADDRESS
,NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO,
USE OF
IL INGS DISTRICT NO, GROUP MAP
MAP PROCESSED BY
BK PG
�U
ADDRESS j
A I
CITY f P z TEL.No, STATION )EPTH
s,
STATE MANHOLE REFERENCE
1 6- COUNTY Z;/,�
REGISTRATION No. I-E,
Na. 1 DESCRIP 10 OF RK FEE
;
HOUSE SEWER CONNECTING
TO
_qL?C SEWER �YPF; C"T CONNrCTI"�_4V,. LENGTH V?ROW
SEPTIC TANK,SEEPAGE PIT OR CURE R IA L, O L,
PITS AND/OR.DRAI N.FIELD @ 2�,
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTH..CESSPOOL,DR WELL
HOUSE SEWER CONNECTING TOJOB No�
PRIVATE DISPOSAL.SYSTEM Co.IMF. No�U
CONNECT ADDITIONAL BLDG,ORTRUNK PERMIT NO� ROAD PERVIT NO,
WORK TO HOUSE SEWER- R, 31.00 0
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM CC9 $1.00 _PERMIT NO,
INDUSTRIAL a-
WASTE APPROVAL _ (/)__
(/)
KARGES z
2 co CONNECTWN CIKARaE rEt
AUTHOERUIZATIO k TOTAL FTE REIMBURSEMENT FEE.
1 HAVE AT THIS PATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONN C: THE ABOVE VESCRIBED EXISTING DWELLING APPROVALS DATE :NS.PE_-T-NiS 31iONAT URE
TO THE PUBLIC SEWEk.
SIGNED MS--DAY OF-- 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT__ �- BUILDING OR WORK
ADDRESSSEPTIC TANK,SEEP,PIT I3�
AND/OR DRAINF'IELD__ __-
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl ORYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DiSPOSAIL.SYSTEM
I HEROY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT
PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF T E�J,AIlOVE
DESCRIBED R .31DENTIAL PROPS, Y. "T BACKFILL SEPTIC TANKS
SEE?.PIT(S) n CESSPOOLS 0
SIGNATURE
v
OF PERMITT E
lVAIMATION ROBERT A. WOOD
CK. 910. r"r SUPERVISING MECHANICAL ENGINEER