HomeMy Public PortalAbout10212 RANDWICK DR_Sewer__ APPLICATt tV OR PERMIT
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COUNTY OF LOS ANGELES EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
NG
JOHN A. LAMBIE, County Engineer 10 Z- 14 r
WILLIAM A. JENSEN, Supt of Building
ST
FOR APPLICANT TO FILL IN RO55 5TH. l? --"—----_ -
- ---- -
LEGAL.
.DESCRIPTION LOT NO, x OWNER
M A I L $ - �ii3 --_
BLO,_K TRACT - FT ADDRE55 E�` ry'^
-- -- -- -- %._' a3+ --- --- --- _ - t mss : - ----
NO, OF BLDG5,
SIZE OF LOT NOW ON LOT CITY em lie Cit-v- At 6281S
USE OF
BUILDINGS � `-� ° DISTRICT Na_ GROUP MAP PROCESSED BY
CONTRACTOR
eg Y:8
DDREss CONNECTION DATA --
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STATION ,+f {, M DEPTH
CITY- "."yy .-s-�.-U--fY--L�"�S-_ �r�
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2 5 M COUTNTY MANHOLE'REFERENCE
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RLGi51 R.47iCN a�
NO. .i DESCRIPTION OF WORK FEE^ _ TYPE.OF CONNECTION »: LENGTH FROM >
HOUSE
SF WER.CONNECi'1NG TO T 'v- CURB P(.. M.L.70 P.L.. ICS.
PUB IC SEW ER — .—_ _._-___— —_ j�
_ $5.00 '..� - --., _,. P C.NO
SEPTIC?hNK,SEEPAGE P(7 6R {
7 AN DRAINFIELD C� �IO.00 ` CO,IMP, NO. JOB NO
HOUSE SEWER CONNECT-NG YO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM. � $3.00
. __� -.---_.__. ..__._— — __—
j CONNECT pp DI T1ONAL BLpG OR ! ! AFFIDAVIT � w.avv€x [nS EM eNi i P.eC ORD. IN5'F2. d0. DATF:
WORK.TO HOUSE SEWER $3.00
!1 XTN.,LES S EPAGE PIF_DRAINFILD
C
E.xTN,C ES SPOOL,DRYW L,MANh OLE @ $5,00
ALTER.REPAIR OR ABANDON HtrI,)SE HWY. OR ST,WIDENING
&EWER OR DISPOSAi SYSTEM _ _$3.00 _ �TA7E ENCROACH MEN7
—_ —_
PERMIT NO.
-
-. INDUSTRIAL.
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ z, Qo
-- -- — CONNECTIONCHARGE FEE
AUTHORIZATION TOTAL FEE � , :"_-
IHAVE Al"-TH(S LATE A C014TRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT"FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX-I STING DWELLING ------ ---- --;r
TO THE PUBLIC SEWER. APPROVALS DeTF INSPF..CTOR'S SIGNATURE
SIGNED THIS DAY —___.—,----
OWNER.OR new
NEW HOt `E SEWER i,: _ _
4i _---
OWNERS ACEPfl7___..�_..__-_ CONNECT ADDITIONAL
BUILDING OR"WOR
K
_AODfRESS
. _ - ! ..T__
..-_
SEPTIC TANK,SEEP,PIT(S)
IH
.ACKNOWL.E'DGE THAT Y HAVE. AND/OR READ THIS APPLICATION !
DRAINF!£LD
AND STx1':. TRAY IH6ABOVE 'iS CORRECT AND AGREE TO COMPLY
WITH ALL COONTY''0,01NANCES AND STATE LAWS REGULATING
P L'_'M GING AND SEWVRS. CESSPOOL. CI DRYWEC.L Q V
IH E80 CFI2TIFY THAT I AM PROPERLY REGIST,E�RED AND/OR ALTER,REPAIR,SEWER OR
LIC'FN ED /§y:'r,E"IRED BY LOS ANGLFrfi17 COUNTY AND S'L'ATE OF SEWAGE DISPOSAL SYSTEM '!
CALIFORNt . OR THAT I AM THE
LE
NER p D INTEND TO D NN --
4a CO. ECT PLUG AND
RESIDE I{. € -- ,/ ,f - ,;_.l _ �,., 5EEP,FPTfS) TANSP L
TH ABOVE OFSt RIBFD ;DENTI L PEftTY AB4N DON HOUSE SEWER
CES
51GNA7UE
OF Pf"14f7TE
OLS
VALIDATIO __—, ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER'
gt CK. M.O CASH