HomeMy Public PortalAbout10072 RANDWICK DR_Sewer__ 3-64
76A642p APPLICATIOW FOR PERMIT
76A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING J 7
JOHN A. LAMBIE, County Engineer ADDRESS _ / ✓ � i.< i
WILLIAM A. JENSEN, Sup"t of Building - "y
LOCALITY _ ,a_-�-
NEAREST
FOR APPLICANT TO FILL IN CROSS STS ` --.
DESCRIPTION LOT NO �// Y OWNER
.____ F _�
-- 114
MAIL
BLOCK TRACT ' '° _ ADDRESS ""• a
NO. OF SLOGS. _ _
SIZE OF LOT NOW ON LOT CITY -J4 ,y,. EL. NO.
USE OF
BUILDINGS m i DISTRICT NO. GROUP MAP P PROCESSED BY
?I_
CONTRACTOR
ADDRESS a > 111 ,: CONNECTION DATA
i'a
CITY NO. ` 'y STATION .::..jt f '�* DEPTH ,
• .L+l `i 4: UPPER
REGISTRATION N0. COUNTY MANHOLE REFERENCE
NO. DESCRIPTTI NNOOF we TYPE OF CONNECTION LENGTH FROM -
HOUSE SEWER CONNECTING TO — - ,.., Y. CURB ��PL. M.L.TO P.L.
PUBLIC SEWER @ $5.00 L' P.C.NO. i }
SEPTIC TANK,SEEPAGE PIT OR i JOB NO "/ > '� CL
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. _ O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, V
PRIVATE DISPOSAL SYSTEM $3.00 ;
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEa EASEMENT I RECORD,INSTR.NO. DATE QS
WORK TO HOUSE SEWER $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MA NH OLE $5,00 HWY.OR STWIDENING t1J
ALTER,REPAIR OR ABANDON HOUSE i . a,
SEWER OR DISPOSAL SYSTEM $3.00 -
._— STATE ENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S CHARGES PERMIT 5I 2 00
AUTHORIZATION TOTAL FEEV, CONNECTION CHARGE FEE
'i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE
ARPTO UBLISITHE ABOVE DESCRIBED EXISTING DWELLING
CONNECT
TOTHEAPPROVALS
DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF _ 19
i
OWNER OR NEW HOUSE SEWER
OWNERS AGENT t - CONNECT ADDITIONAL
BUILDING OR WORK >,
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 COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MBI.NG AND 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 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ASOv"DESCRIBED RESID fA ..,PROPERTY. ABANDON HOUSE SEWER
SIGNATUREo— _ BACKFILL SEPTIC TANKS ❑
OF PERMITTEE__ El_ - E]--- SEEP,PIT(S) CESSPOOLS
�'"VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
J