HomeMy Public PortalAbout10054 RANDWICK DR_Sewer__ A 6
- 4
76642D APPLICATION FOR PERMIT
78A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TN
DING
JOHN A. LAMBIE, County Engineer RESS 41�� �
WILLIAM A. JENSEN, Sup't of Building .,.:
ALITY _ S
REST
FOR APPLICANT TO FILL IN ss sr.
_--LEGAL
DESCRIPTION LOT NO. OWNER
/// MAIL
BLOCK TRACT __ � y ADDRESS_ iW
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY
USE OF— -- y-
BUILDINGS DISTRICT NO. GROUP AP P. PROCESSED BY
CONTRACTOR
ADDRESS s .y CONNECTION DATA
CITY -- TEL. NO. _ _ STATION ;� f° DEPTH
Y "r '-STATE MANHOLE REFERENCE 4 y� ! Y" UPPER
REGISTRATION NO. YJN7Y y - - L4& Eft
NO. DESCRtPTION�YORK FE—e
_ TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO Y. CURB At L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 I +_ P.C,NO �,.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CO,IMP. NO. JOB NO 350.00 I_ .--- Z v O.
HOUSE SEWER CONNECTING TO i TRUNK PERMIT NO. ROAD PERMIT NO. (�
PRIVATE DISPOSAL SYSTEM $3.00 --i—
CONNECT ADDITIONAL BLDG.OR AFFIDAVti 1 WAIVER EASEMENT RECORD.INSTR.NO, DATE Ix
WORK TO HOUSE SEWER @ $3.00 ! O
_rOVERFLOW SEEPAGE PIT,DRAINFIELD _� f—
EXTN..CESSPOOL,DRYW ELL,MA NHOLE 0 $5.00 V
LLJ
ALTER,REPAIR OR ABANDON HOUSE Q_
HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM E3.00 - --- Q
--.--- — STATE ENCROACHMENT N
PERMIT NO. z
I � INDUSTRIAL
! WASTE APPROVAL
CHARGES
OWNER`S PERMIT $ 2 0
i�
AUThORIZATION TOTAL FEE CONNECTION CHARGE FEE
f �'!v;•—�
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --
TO THE PUBLIC SEWE - APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS Y O!_ _1 d --
OWNER OR ;y'' _ NEW HOUSE SEWERQNa� 1
OWNERS AGENT _
y CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS---
SEPTIC
DDRESS_ .—
i HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR
TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY P`ND/OR DRAINFI E[.D
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 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 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AR,O.ILE.,_DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREBACKFILL SEPTIC TANKS ❑
OF PERMITTEE_
SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
q CK. - M.O. CASH