HomeMy Public PortalAbout10762 LYNROSE ST_Sewer__ 7CA64= I
^E608If-57 APPLICATION FOR PERN41T le,
COUNTY OF LOS ANGELES SEWER—SEWAdDISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIL
JOHN A. LAMBIE, County Engineer ADDRW '162 _11ealrorse
CASSATT D. GRIFFIN. Sup't of Building /X-'
ALITY ty
NEAREST
OR APPLICANT TO FML IN CROSS ST.
LEGAL
DESCRIPTION LOT NO.
OWNER�,)'(' _13
T
BLOCK TRACT2'5"C" MAIL
ADDRESS -.7-,
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT io.
USE OF rc
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR
ADDRESS'R o. C CONNECTION DATA
3 ,x- 2 - T)
Ealdv,i
ln 1;a
CITY _T"' TEL NO. STATION
DEPTHy .
61STATE MANHOLE REFERENCE UP
REGISTRATION NO. 3 COUNTY
LOWER
NO. _DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO I
PUBLIC SEWER 6- - I . 00 TYPE OF CONNECTIOW, LENGTH FROM
SEPTIC TANK, SEEPAGE PIT OR -
PITS ANDIOR DRAI NFIELD $3.00 Y. CURB M.L. 10 P.L.
OVERFLOW SEEPAGE PIT,DRA!NFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE Q $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. Jo,"'O'
CONNECT ADDITIONAL RLDG,OR
WORK I'D HOUSE SEWER Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM (a $1.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL CHARGES
OWNER'S PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 5100 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 THISDAY OF 9-- NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL 7
OWNERS AGENT New BUILDING OR WORK
ADDRESS- SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINrIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND
STATE THAT THE ABOVE 15 CO RRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL El
WITH ALL, COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REOUIRED BY LO ELES COUNTY AND STATE OF DISCONNECT PLUG AND
G UN
CALIFORNIA OR THAT J AM 1 EGAL OWNER OF THE ABYE ABANDON HOUSE SEWER
DESCRIBED RESIDEN. PROPER BACKFILL SEPTIC TANKS El
SIGNATURESEEP. PIT(S) ❑ CESSPOOLS L
OF PERMITT
I)F VALIDATION ROBERT A. WOOD
CK. m.O. CASH SUPERVISING MECHANICAL ENGINEER