HomeMy Public PortalAbout10102 RANDWICK DR_Sewer__ / t
CE808 3-E4 Jy
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_ >'; '/ - dL
WILLIAM A. JENSEN, Supt of Building ✓' `y
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
---- . -
LEGAL
DESCRIPTION LOT NO, OWNER l'
.--___--._ �
,,CC MAIL rr
BLOCK -_ TRACT J' � ADDREBS
NO. OF BLDGS•
SIZE OF LOT NOW ON LOT CITY �-� .��_�- -_� L. NO.
USE OF r
BUILDINGS -- DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR
ADDRESS w� _ CONNECTION DATA ._.
STATION .-� DEPTH
CITY -TEL NO. UPPER
STATE MANHOLE REFERENCE + f
REGISTRATION NO. �y!r _ COUNTY ✓t 1 _f 1
NO. GESCRIPTIONF6 WORK FEE E__ TYPOF CONNECTION � LENGTH FROM
HOUSE SEWER CONNECTING TO 'I- Y. CURB r.L` M.L.TO P.L.
PUBLIC SEWER $5.00 - `'G,
�-� P.
NO
SEPTIC TANK,SEEPAGE PIT OR ✓' ''I' 4.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
DISPOSAL SYSTEM @ $3.00
PRIVATE
_ _ —{I.— _.__.__
CON NECTADOITIONAL BLDG.OR — I AFFIDAVITwAiYER EASEMENT RECORD.INSTR.NO. DATE
I WORK TO HOUSE SEWER @ $3_00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 `J,I
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
1 SEWER OR DISPOSAL SYSTEM @ f3.0� STATE ENCROACHMENT Z
---._—T_—_— _ PERMIT NO.
---- - INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT _ $1 2 00 — —
AUTHORIZATION TOTAL FEE ' CONNECTION CHARGE FEE '—
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONISEEP.
MBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINAPPROVALS
TO THE PUBLIC SEWER,...- DATE INSPECTORS SIGNATURE
SIGNED THIS DAA OFt --"----" — — pqe
OWNER OR �.." f { HOUSE SEWER '
r
�l a "-
OWNERS AGENT - r -"�-- NECT ADDITIONAL
DING OR WORKADDRESS_IHEREBY ACKNOWLEDGE THAT1HAVE READ THIS APPLICATION IC TANK,SEEP,PITS)
�ORDRAlNFIELDAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYWITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGSPOOL ❑ DRYWELL ❑PLUMBING AND SEWERS.! HEREBY CERTIFYTHAT 1AM PROPERLY REGISTERED AND/OER,REPAIR.SEWER-ORLICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFAGE DISPOSAL SYSTEM
CALIFORN(A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TOONNECT PLUG AND
RESIDE IN, THE AEI iVE-Y5ESCRISEO RESI MTAAL PROPERTY. NDON HOUSE SEWER
SIGNATURE - X' J KFILLSEPTIC TANKS ❑OF PERMITTEE ,PIT(5) ❑ CESSPOOLS
_VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
M.0, CASH