HomeMy Public PortalAbout10060 RANDWICK DR_Sewer__ CEBo® a-aa.
76a642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building -�—
LOCALITY
NEEARERRE ST � ----_J----
FOR APPLICANT TO FILL IN CROSS 5T. = — -
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DESCRIPTION LOT NO. OWNER ✓
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MAIL / J
BLOCK TRACT_ Lf� J ADDRESS <"' j /,
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY `} TEL. NO.
USE OF ---''
BUILDINGS ..„ DISTRICT NO. GROUP[�'y MAP PROCESSED BY
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CONTRACTOR_
ADDRESS �,y' .. CONNECTION DATAs_�_
CITY
.,TE NO. _--I STATION DEPTH
PATE MANHOLE REFERENCE COUTREGISTRATION NO.
— LOWER
—/ A
NO. DESCRIPTION OF WORK
FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO � _ Y._ CURB P.L. —M-L.TO P.L. _ —6f
PUBLIC SEWER 85.00
P.C.NO
EPTIC TANK,SEEPAGE PIT OR 0
CO.IMP.NO. JOB NO
PITS AND/OR DRAINFIELD @ $10.00 --
�HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM @ $3.00 _
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wlllvf8 EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOWEE PIT.DRAINFIELD �_,_
EXTN..0 ESSPOOL.DRYW ELL.MANHOLE @ $5.00 L!J
HWY. OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE _—_ N
SEWER OR DISPOSAL SYSTEM @ $3.00STATE ENCROACHMENT - Z
1 -_ ---- PERMIT NO.
--- INDUSTRIAL
WASTE APPROVAL _JT
T� CHARGES
OWNERS PERMIT $1 2 00 _
AUTHORIZA'T'ION TOTAL FEE r CONNECTION CHARGE FEE —
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR 70 CON. CT THE ABOVE DES RIBED EXISTING DWELLING �--
TO THE PUBLIC SIE APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF E ---
OWNER OR .. NW HOUSE SEWER
OWNERS AGENT --" - CONNECT ADDITIONAL
sn
BUILDING OR WORK - 11
ADDRESS—
SEPTIC TANK.SEEP.PiT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO
WITH ALL COUNTY ORDINANCE AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWL —
t HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND i OR ALTER,REPAIR,SEWER SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN iA OR THAT 1 AM THE LEGAL OWNE ,QF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THEABOVE RJOED RESID IA ROPERTY, ABANDON HOUSE SEWER
SIGNATURE - 4.,..-+'^" BACKFILL SEPTIC TANKS ❑ 1
OF PERMITTEE SEEP,PIT(5) ❑ CESSPOOLS ❑
`VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK, M.O. CASH
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