HomeMy Public PortalAbout10733 LYNROSE ST_Sewer__ 76AB420
CES08 11-57 APPLICATION FOR PERMIT
COUNTY Or LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
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BUILDING AND SAFETY DIVISION BUlLDING
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JOHN A. LAMBIR, County En user ADDRESS
CASSATT D. GRIFFIN, Sup't of Building LOCALIOCALI
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NEAREST
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FOR APPLICANT TO FILL IN CROSS ST.JJIV'(: Cak
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DESCRIPTION LOT NO, 5 OWNER Icri Con
MAIL
BLOCK TRACT 2 4 5 T-) ADDRESS 0-�,,c,- lizusa -r
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NO.OF BLDGS. '7F, -
SIZE OF LOT NOW ON LOT CITY �,-;- �;!�:(-, ` 35C�14
CITY 0:; TEL.NO
USE
DISTRICT NO. GROUP MAP
BUILDINGS e lent
CONTRACTOR • . ,:,- . C c a<? Y U c–5 1 G,n c PG
ADDRESS Bcxx 4n DATA
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STATION
F TEL.L.N 0. DEPTH
CIT -'E�d. 8
REGISTRATION STATE. MANHOLE REFERENCE
COUNTY
NO.f—b—ESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR TYPE OF CONNECTIONLENGTH FROM
PITS AND/OR DRAINFIELD $3.00 Y. URB L!, M.L.TO P,L.
OVERFLOW SEEPAGE PIT,DRAiNFIELD
EX7 N.,CESSPOO L,DRYWELL,MAN 40LE $2.00
HOUSE SEWER CONNECTING TOP C.NO-
PRIVATE DISPOSAL SYSTEM CO.IMP.NO.
$1.00
JOB NO.
CONNECT ADDITIONAL BLDG.OR
IV_q RK TO W
HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
- -
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 I STATE ENCROACHMENT
--nLf�mly NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s ---A 00 CONNECTION CHARGE FEE
5
AUTHORIZATION TOTAL FEE
m� � REIMBURSEMENT FEE
IHAVE 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 OF---I 9— NEW HOUSE SEWER
OWNER OR TTFsr,rr CONNECT ADDITIONAL
OWNERS AGENT 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[I DRYWELL[D
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR.
CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
R.
I HER By SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED B, LOS Alq!�Z6-FS COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE 'LEG OWNER OF THE ABO ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA,]-- BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP. PIT(s) Cl CESSPOOLS El
OF PERMITTEF
IS
-VALIDATION ROBERT A. WOOD
U.0. CASH SUPERVISING MECHANICAL ENGINEER