HomeMy Public PortalAbout10052 RANDWICK DR_Sewer__ 3-E4
76A6420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FEAREGIT
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JOHN A. LAMBIE, County Engineer 5 d' � �---
WILLIAM A. JENSEN. Sup't of Building s
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FOR APPLICANT TO FILL IN ST,
LEGAL --�
DESCRIPTION LOT NO. OWNER
a _ MAIL c
BLOCK _ TRACT � 'f �" _ ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY .� TEL. NO.
USE OF --- — --J----
BUILDINGS ty ..+�' DISTRICT NO. GROUP MAP PROCESSED BY
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CONTRACTOR , (, _ y� - _- �' /.(.:+3
ADDRESS j .SSS...-Sii__.......--- a'`:�-- -�'. f _ 'Fz - _ CONNECTION DATA
�- -LJ ,/'- - �r STATION -v '� DEPTH
CITY �— +.�`. TEL NO. - _- ice" 1 J .._ ?�•
' -STATE _ UPPER
t MANHOLE REFERENCE —_ *
REGISTRATION NO. ?' j . COUNTY ri'�. I _LUPCn_
It
N0. DESCRIPTION F WORK "t _ TYPE OF CONNECTION LENGTH FROM /
=HOUSE SEWER CONNECTING TOC
' Y_ CURBL.I M.L.TO P.L.
PUBLIC SEWER @ _$5.00 P.C.NO.
•4iZPTIC TANK,SEEPAGE PIT OR l Co. IMP.NO. .108 NO. - ?�!�� 06
PITS AND/OR DRAINFIELD 510.00 ---- —
H_0 US E SEWER CONNECTING TO — TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM Q $3.00 _
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK'1'O HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00
-- - HWY.OR ST.WIDENING IJ.
, AL7E R,REPAIR OR ABANDON HOUSE - �
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
--- -- I PERMIT NO. ^- Z
-------- ---
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT a 21 OO -- CHARGES
'�-- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ,, j.-, "I -------- — ----
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - APPROVALS
TO THE PUBLIC SEW DATE INSPECTOR'SSIGNATURE
SIGNED THIS DAY OF
OWNER OR -' NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
c. —_P_.----
ADDRESS_ #_ - ------ SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - —
WITH ALL COUNTY ORDINANCE AND STATE LAWS REGULATING '"
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ ,
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM �I— ±—
,CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB VE DESCRi B+F_D R ENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE \ BACKFILL SEPTIC TANKS ❑
OF PERMITTEE /"t_+L ❑
SEEP,PIT(S) ❑ CESSPOOLS
11 VALIDATION ROBERT A. WOOD/ SUPERVISING MECHANICAL ENGINEER
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� J M.O. CASH
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