HomeMy Public PortalAbout10059 RANDWICK DR_Sewer__ i
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76A642D APPLICATION FOR PERMIT
A54
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADDRESS} JBY
WILLIAM A. jENSEN, Supt of BuildingLOCALITYNEARESTFOR APPLICANT TO FILL IN CROSS ST.DESCRIPTION LOT NO. / OWNERD__ MAIL
BLOCK TRACT ltijADRESSNO. OF BLDGS,
SIZE OF LOT NOWON LOTCITY `.. qy�,- 7•L. NO.
USE OFBUILDINGS + _ DISTRICT NO. GROUP MAP PROCESS
BK PG
t i
'CONTRACTOR y✓ ,,..,r ��
ADDRESS+ ✓�:`('' CONNECTION DATA _
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, . -- vSTATION ]DEPTH
CITY Q. _ K
CL_
TATE
REGISTRATION NO -moCOUNTY MANHOLE RE FERENC E ,. `` `.�..a7 - LOWER
NO. CESCRI PTION 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 P.C.NO -
SEPTIC TANKSEEPAGE PIT OR I}-'--< / �
PITS N
AD/OR DRAINFIELD @ $10.00 CO.IMP. NO. ___ .706 NOy,i.
a.HOUSE SEWER CONNECTING TO — TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE c`
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD I —�_ �___
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 —J i UJI
ALTER.REPAIR OR ABANDON HOUSE ^_ �-' HWY.OR ST.WIDENING
SEWER_OR DISPOSAL SYSTEM- $3.00 -- '— -- Z
---- —.__._ —__.__ _ STATE ENCROACHMENT
PERMIT NO.
---- - INDUSTRIAL — —
I WASTE APPROVAL
CHARGES
OWNER'S PERMIT $1 2 00 _ —
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
j
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGp� c —'------
TO THE PUBLIC SEWS � '}.. I / � APPROVALS' DATE INSPECTORS SIGNATURE
SIGNED THIS BAY OF
OWNER OR -,,, - NEW HOUSE SEWER q
OWNERS AGENT . —_ .__...___
�� CONNECT ADpITIONAL C
BUILDING OR WORK
ADDRESS "y�"} _-"W.`."."•"�"_`""`.-'_.... -- _�_�
SEPTIC TANK.SEEP,PITS)
I 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 ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER ORCE
LICENSE AS REQUIRED BY LOS ANGLES COUNTY AND STATE 01' SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT t AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV �S CA BED RESID .,PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEEr c _ _ SEEP.PIT IS) C3 CESSPOOLS ❑
/,'-VALIDATION ROBERT A. WOOD
J r SUPERVISING MECHANICAL ENGINEER
CK./ M.O. CASH