HomeMy Public PortalAbout10769 LYNROSE ST_Sewer__ 76AU420
CFF306 11-57 APPLICATION FOR PERN!IITAe, 7?-,
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDI G-
TOHN A. LAMBIE, C Eni AD -Lyn se 1--tel"ou rear
CASSATT D. GRIFFIN, &:lt of Building
LOCALITY— uy
NEAREST
FOR APPLICANT TO FILL IN —CROSS ST. Live Cak
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT 4 MAIL
ADDRESS
NO.OF BLDGS.
cn
S17E OF LOT NOW ON LOT CITY TEL.NO. %'T 5014
USE OF
BUILDINGS U DISTRICT NO. GROUP MAP
L C
__? -_IC4
PG
CONTRACTOR L uc t i ork IC
L4;s U /16?
ADDRESS 'kcx 208 CONNECTION DATA
3-�024 STATION DEPTH
C143"_3"d."N'n Par-l�: TEL,NO. -ujd. -.:;C)24 _Z, "i
STAT MANHOLE REFERENCE
[REGISTRATION NO. 1-136.13 COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 00
SEPTIC IC TANK,SEEPAGE PIT OR TYPE OF CONNECTIO.X-j� LENGTH FROM
PITS ANIVORDRAINFIELD @ $3.00 Y. CURB ` M.L.TO P.L.
OVERFLOW SffffAGE'PIT,DRA114FIELD
EXTN.,CESSPOOL,?_RYWELLMA.NHqL�- @ $2.00__
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00
CO,IMP.NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00
TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER,REPAIR®R ABANDON HOUSE
_SEWER OR DISPOSAL SYSTEM 4 $1.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE,APPROVAL CHARGES
OWNER'S PERMIT 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 5 00 REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS 1 DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THISDAYOF_ 19— _N_E�WHO"E SEWER
OWNER OR 'New. CONNECT ADDITIONAL.
OWNERS AGENT BUILDING OR WORK
ADDRESS— SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAI FIELD
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[I DRYWELL[I
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 REQUIRED BY LOS ANG-LES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT. AM THE L2GAL,OWNER 07 THE AB _ ABANDON HOUSE SEWER
DESCRIBED REsLDFNTvAVPRo?Eq
BACKFILL SEPTIC TANKS []
SIGNATURE SEEP. PIT(S) El CESSPOOLS 0
OF PERMITTEES'
VF VALIDATION ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER