HomeMy Public PortalAbout10049 RANDWICK DR_Sewer__ f
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76A642D APPLICA I - a ...R PR '',
COUNTY OF LOS ANGELES SEWEt-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCROSS
-
JOHN A. LAMBIE, County Engineer r"
WILLIAM A. JENSEN, Sup't of Building
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FOR APPLICANT TO FILL IN ---
DESCRIPTION_ LOT NO. OWNER
MAIL _
BLOCK TRACT _„y f, � F f!' ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY
USE OF F
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG ;
CONTRACTOR `/�- G.....
LADDIRESS ;�; .,3. _ CONNECTION DATA
STATION /. DEPTH
YEL NO.
— UPPER
REGISTRATION NO. � - re --TATE Y MANHOLE REFERENCE
COUNT
NO. DESCRIPTION OF WORK FEE __ TYPE OF CONNECTION LENGTH FROM ,!
HOUSE SEWER CONNECTING TO —� Y _ CURB '-:P:L: M.L.TO P.L.
PUBLIC SEWER @ $5.00.
SEPTIC TANK SEEPAGE PIT OR '— P.C.NO.
10.00 CO.IMP. NO. JOB NO. J >
a.
PITS AND/OR DRAINFIELD $
@ _.._—_ __ f , y
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WRIYEk EsS EMENT RECORD.INSTR.NO. DATE /�/�
ER
WORK TO HOUSE SEWER b3.0 — - �— V.
OVFLOW SEEPAGE PIT,DRAINFIELD - U
EXTN„CESSPOOL,DRYWELL,MANHOLE $5.00 LU
ALTERR
. EPAIR OR ABANDON HOUSE HWY.OR 5T.WIDENING 93-
SEWER OR DISPOSAL SYSTEM. $3.00 -- - — --- ----- Z
STATE ENCROACHMENT
— PERMIT NO. z
- --- —I - INDUSTRIAL— --- —
WASTE APPROVAL
OWNERS PERMIT_ $2, pp _CHARGES
- CONNECTION CHARGE FEE -
AUTHORIZATION TOTAL FEE ---- -
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SEW' APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF ' ,4 1 L -----
OWNER OR v NEW HOUSE SEWER -
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS__-__
SEPTIC TANK.SEEP,PIY(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD I
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ------ —
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM
PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY L.OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO, f?CRTBED REST TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE !” " BACKFILL SEPTIC TANKS ❑
OF PERMITTEE A' -- SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.) M.O. CASH
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