HomeMy Public PortalAbout10120 RANDWICK DR_Sewer__ CE808
76A64A6420 APPLICATION FOR PERMIT
(�
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY-DIVISION FNEAREST
A
JOHN A. LAMBIE, County Engineer °� " j-
WILLIAM A. JENSEN, Sup't of Building r"w
FOR APPLICANT TO FILL IN --
_- —
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT . ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT / _ CIT' EL. NO.
USEOF � I
BUILDINGS 1s_—_ DISTRICT NO. GROUP MAP PROCESSED BY
__— BK PG
CONTRACTOR .
ADDRESS _- CONNECTION DATA ---
STATION t DEPTH
CITY —ftEL. NO.
O � / COUNTY LOWER
MANHOLE REFERENCE
REGISTRATION N :
_ .�' u�- d Y. 'J ._j r _-�.
NO. GESCRI PTI OM'-- OF WORK FEE _ TYPE OF CONNECTIONLENGTH FROM -a
,p✓ HOUSE SEWER CONNECTING TO Y. CURB L. M.L-TOP.L
OP.L
PUBLIC SEWER _-@ $5.00
.SEPTIC TANK.SEEPAGE PIT OR P.C.NO ' j�•' 0.
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO. JOB NO f
HOUSE SEWER CONNECTING TO O
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR — T AFFI DAVIT T—Wp1veR EAS[ME MT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 I � O
OVERFLOW SEEPAGE PIT.DRAINFIELD _--L--__—.
EXT N.,CESSPOOL,DRYWELL,MANHOLE @ $5-00 W
ALTER,REPAIR OR ABANDON HOUSE. HWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO. L•
-- INDUSTRIAL ---
W ASTE APPROVAL
--�-- CHARGES
OWNER'SPERMIT_-- -- 2 00 - --- -
AUTHORIZATION TOTAL FEE p y CONNECTION CHARGE FEE _—
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEW DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF ' "' 1 ------ – —
OWNER OR _ N£W HOUSE SEWER
OWNERS AGENT-
CONNECT ADDITIONAL t
C BUILDING OR WORK
ADDRESS, .-i'-v..'�ro ..t=,.
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT 1 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
PLUM RING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOW RED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE q,BOV `DESCRIBED RESPROPERTY. ABANDON HOUSE SEW ER
SIGNATURE '`1 A' -' ❑ iL
BACKFILL SEPTIC TANKS
OF PERMITTEE__.� v -a
== SEEP.PITS) ❑ CESSPOOLS 01
"`VALIDATION ROBERT A. WOOD
,Jljf SUPERVISING MECHANICAL ENGINEER
M.0. CASH