HomeMy Public PortalAbout10114 RANDWICK DR_Sewer__ TEMPLE CITY
'6A 642D -CE808 -10-71 APPLICATION FOR PERMIT -
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
q �y �qT� -�v1r.� °°yy //''ttit fYm ye CiFOR APPLICANT TO FILL INIc :nan
LEGAL Chris
r� p
DESCRIPTION LOT NO. �yC/ ,{ OWNER Chris 1,3ade
BLOCK TRACT JI.�,/ Y` x ADDRESS 6002 MAIL N N . Burton
NO. OF BLDG$.
SIZE OF LOT NOW ON LOT CITYSan GahrlTEL. NO. �, 1 "
USE OF
BUILDINGS _ �Lje.Ci DISTRiCTNO.1 GROUPI
BK MAP PROCESSED BY
. J P3
'I� a,
CONTRACTOR Square trPid_l Sewer Service
ADDRESS 2933 Mai son Rd. CyONNECnON DATA _
CITY El 'conte TEL- NO. 4 STATION _...d:,; F � DEPTH
"C f UFP
STATE �'II ry8�-�8Q�7 �j LIC MANHOLE REFERENCE t
ICENSE NO.•+1.(v V V(0 CLASS C-4(.e ( y pj LOWER
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTIONii--s- LENGTH FROM
L.
CONP
vim
qq HOUSE SEWER NECTING TO Y. CURB ��P.L. M.L.TO P.L.
1. PUBLIC SEWER @ $7.00 0
SEPTIC TANK.SEEPAGE PIT OR
76
PITS AND/OR DRAINFIELD ;10.00 CO. IMP.N O.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 83.00
CONNECT ADDITIONAL BLDG..OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR-NO. DATE u
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD Ix
EXTN..CESSPOOL.DRY W ELL. @ $5,00 HWY.OR STWIDENING O
. .
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3.00
---. ----- - STATE ENCROACHMENT
LJINHOLE � $7.00 PERMIT NO. _ d
----------- ---- INDUSTRIAL 1)
WASTE APPROVAL Z
OWNERIT S PERMS 3 00 CHARGES
AUTHORIZATIONJ TOTAL FEE 1 1-0 00 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER �f fyr
OWNERS AGENT �---
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS_
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CE55POOL ❑ ORYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT i AM THE LEGAL OWNER F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENT L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE - BACKFILL SE-PTIC TANKS ElOF PERMTTTE ---- SEEP,PITIS) ❑'-CES$POQLS ❑
VALIDATION CK. 'm.0. CASH