HomeMy Public PortalAbout10633 LYNROSE ST_Sewer__ /I z
DEPARTMENT OF COUNTY ENGINEER '� 'f( , �s-, f 4,(r ,
DIVISION OF BUILDING AND SAFETY Sk�iIVER-SEVV�►C�E DISPOSAL
PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
CASSATT D. GRIFFIN, SUPT OF BUILDING ADDRESS —
FOR APPLICANT_.TO FILL IN LOCALITY
BUILDING / �' NEAREST
ADDRESS CROSS ST. ,
LOCALITY �w `T r DISTRICT N0. SERIAL N0. PERMIT N0.
NEARESTr v R S
CROSS ST. ✓ Gj—
,1!4 RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
_ADDRESS � ,a"r }' } i L,—"'� USE ZONE OCCUPANCY BK MAP PC
CITY ! _ TEL.NO
CONTRACTORa1 L !r �; .rj y _. CHARGES REIMBURSEMENT FEE
4 ?
ADDRESS REQUIRED'� •,.J�`_."�✓ _._.�•,> _ ._.
CITY ry ,p TEL.NO. �j�' NOT REQUIRED
--- � .y "/`i`d's /, JOB.NO. CONNECTION CHARGE FEE
STATEE -
REGISTRATION NO. % ''"7 COUNTY CO.IMP.NO.
LEGAL RECEIPT NO. DATE { BY
DESCRIPTION LOT NO.
BLACK TRACT - WAIVER FOR RECORDING
SIZE OF LOT NO.OF BLRECEIPT NO. DATE I BY
_ NOW ON L0O7T
USE OF
BUILDINGS
TRUNK PERMIT NO.
NO.I DESCRIPTION OF WORK, FEE _
HOUSE SEWER CONNECTING TO s ROAD PERMIT NO.
PUBLIC SEWER @ $ 3.5_0
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1.00 PERMIT NO. _
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
_ WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER 911REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM__ 1.00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER —
AND/OR DISPOSAL SYSTEM 1.00 STATION DEPTH
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 MANHOLE REFERENCE
CESSPOOL—DRYWELL I I UPPER LOWER
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH.FROM '
Y. CURB P.L. M.L.TO P.L.
OWNERS _PERMIT _$ 1 oo --
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TQ THE PUBLIC SEWER _
SIGNED THIS.-.-._ - -._DAY OF. .......... 19`� NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL
OWNERS AGENT - -- �` BUILDING OR WORK
ADDRESS � � .. SEPTIC TANK,SEEP.PIT(S)
l
_ - 1i c"y m.�m 'AND/OR DRAINFIELD
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[jDRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATENG PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ----
AND/OR D AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND ST E OF LIFORNIA OR THAT i AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABO E DESCRIBED RE IDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
'��„=-� � SEEP.PIT(S)0 CESSPOOLS
SIGNATOR '"� �.r a �-
OF PERMIT - ---- ------
,6A6421)
;6.16421) 663 12/52