HomeMy Public PortalAbout10053 RANDWICK DR_Sewer__ CE808 3-E4
76a642D APPLICATION FOR `PERMIT
COUNTY OF LOS ANGELES ,I
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER u
BUILDING AND SAFETY DIVISIONBUILDING (
JOHN A. LAMBIE, County Engineer ADnREss �c e,-5
WILLIAM A. JENSEN, Supt ai Building --�� ---
LOCALITY `
NEAREST j
FOR APPLICANT TO FILL IN CROSS ST.
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DESCRIPTION LOT NO. OWNER ' ,a
MAIL
BLOCK TRACT ADDRESS 4 V '-�'
NO. OF SLOGS.
SIZE OF LOT NOW ON LOTTEL. NO,
CITY :,. E
USE OF •�
BUILDING'S .,�i_-: - DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR —.
ADDRESS " s CONNECTION DATA _
CITY '` ='r ,:TEL. NO. _J ""`+' STATION ,� v DEPTH
_
REGISTRATION NO. , ''�' .r d COUNTY MANHOLE REFERENCE 7
`Ls _ f"' -7 a✓..'.��"-.(. s.� LOWER
NO. GESCRIPTION_ 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,
P I1P AND/OR DRAINFIELD $10.00 CO. IMP. NO. JOB NO. 'gyp / ' �a
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.� (0
PRIVATE DISPOSAL SYSTEMS $3.00
CONNECT ADDITIONAL BLDG.OR _ AFFIDAVIT WAIVER EASEMENT RECORD,I.NSTR,NO, DATE 04
WORK TO HOUSE SEWER $3.00 I 0
OVERFLOW SEEPAGE PIT,DRAINFIELDt—
EXTN„CESSPOOL,DRYWELL,MA NH OLE(11_$'5.00 V
ALTER,REPAIR OR ABANDON HOUSE v HWY.OR ST.WIDENING UI
I SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT �—
PERMIT NO. - Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE -r
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING OWEL.ING APPROVALS
TO THE PUBLIC SEWS ,�� DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAX OF 18
OWNER OR - _. NEW HOUSE SEWER r
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS— - BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANC E3 AND STATE LAWS REGULATING
PLUMBINGAND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED R TIp "PROPERTY.SIGNATURE ABANDON HOUSE SEWER
OF PERMITTEE - - - BACKFILL SEPTIC TANKS
- - SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
�K'/� SUPERVISING MECHANICAL ENGINEER
M.O. CASH
0
9 OG FAN 17 1 0 D 7.0 0- Z