HomeMy Public PortalAbout10206 RANDWICK DR_Sewer__ 16A6420 62
D APPLICATION FOR PERMIT
IS AG 42
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
:BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE County Engineer ADDRESS _lop �^ �����f
WILLIAM A. IENSEk, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN GRO55 57. C # Ave.----------------
LEGAL.
^ESCRtPTION LOT NO, e- OWNER
MAIL
BLOCK TRACT d -_ -.-_ _ ADDRESS 1T7
NO. OF BLDGS.
SIZE OFL,OT NOW ON LOT � CITYI 'Q It
..-,NO. • lt^ q.
USE fI Residence
BUILDINGS »LVx7 (,.Z.4b.kf e DISTRICTNO. GROU7 M,9P PROCESSED By
EiK PG
CONTRACTOR 0
ADDRESS s, r - ' jeCONNECTION DATA
:$'
3o .
^t San Il- � t.t:f AT'S ON --�_, /. ;( DEPTH
CITY o . Jr i.e�-.-•i3.1�- --.O _
F"1*,a —_— STATE MANHOl E REFERENCE
RLGISTRA.iiON pJ c�so �� COUNTY _ � LOWER--� -
NO L7ESCRI�TION OF WORK FEE - --- --
_ IYPE OF CONNECTf OR LENGTH FROM
HOUSE SEWER CONNECTING TO _T fpr Y --c-URB ____�>..` WL TO P.L.
PUBLIC SEWER $r.00 1 `__- - --_.-
SEPTIC.TANK,BE EPAGE AIT OR -- r " _..-- JOP. NO
PIPS A.ND OR DRAINFiELD @. CO..IMP, NQ. JOB NO
$10.00 _.._.-__.-_--___--_..__._._._.-- -._..� "_-„'
HOUSE CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL,SYSTEM
-___.-_._-.-__- RE-C-0-RD.
_-_ - --_-- _-
CONNECT ADG TIONAL BLDG.OR �----- - AFFIDAVIT ViT � >i'Alv[4 [zs[�t[ar j Rcc ORD, INSY'R.NO. � DA _
WORK TO HO 'SE SEWER Q $3-On t
,
OV ERF L.OW SEEPAGE PIT,Of2A7NF E-LD
1 EXTN.CE..SSPOOL.DRYWE.LL.MA OLE L ff,5.00
NH
.
HWY..OR ST:WIDENING
• 4LTER.REPAIR OR AS INDON HOUSE � —
SEWER OR D95PCSAL SYSTEM @ $3:00 j STAT£ENCROACHMENT
PERMIT ANO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
�'p
OVMERS PERMIT z. oo _ -_--- ---- _ --_-- --------_ -_-_-----
AUTHORIZATION TOTAL FEE ✓ - CONNECTION CHARGE FEE
I AVE AT T'F?f.S DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
'TRACTOR TO CONNECT' THE ABOVE DESCRIBED EXISTING DWELLING --- y7��gy�--/-� ---T-- - ---r- - ----� ---
TCT THE PLIBLIC SEWER. APPROVALS ALS IDA C j INSPECTOR 5 SIC NATURE
__- __.i-_. _ ---__. _.�_ -___ __
SIGNEC7 THIS BAY OF ___ ___:19._. ---_-- -
OWNER OR r.k ` NEW HOU E SEWER ,
OWNERS AGENT_-._
_-_-�_._ __...-. _ 'ONNECT ADDII ZONAL `` A
ADDRESS. BUILDING OR WORu
_-- - .._� .-- -_ i-- -1
SEPTIC TANK, EFP,PI?(E) I
I HEREBY ACKNOWLEDGE THAT 1 HAVE REAL) THIS APPLICATION AND/OR DRA NF ELD
AND. _TAP .E THAT THE ABOVE !S CORRECT AND A/_HEF TO COMPLY
WITH ALL COUNTY Ot4DINANC£S AND STATE LAWS REGULATi NG
PL.UMcING .AND SEWERS. CESSPOOL C1 DRYNEL.L ❑ �
HEREBY CERT IFR .,SAT I AM PROPERLY REGISTERED-AND/OR ALTER,REPAIR.SEWER OR 1
LIC=ENSED AS REVUIR'tD BYLOS ANGLE 5 4.OUNTY AND OTA.TE OF SEWAGE DISPOSAL.SYSTEM � 1
CALIFORNIA OR T i AM THE LEGAL CAHT ER Oc AND ?NTEND TO DISCONNECT i UG AND
F.ESiDE IN. 'i' is/e OV.E DESCRIBED RES�3E`P1,TIALy.PROPf RTY.
iN - � ABANDON HOUSE SEWER.
E
SIGNATUR ._-
99 B -KFILL SEPTIC TANKS
or SEEP.PIT 15) L7 CESSPOOLS
VALIDATION ---- ROBERT A. WOOD
1 K. M.a CASH SUPERVISING MECHANICAL ENGINEER
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