HomeMy Public PortalAbout10217 RANDWICK DR_Sewer__ 16A64?O APPLICATION FOR PERMIT
COUNTY Of LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION HN gieBUILDING
A
_ _ !7 __ z
JOA. LAMBIE. County Enner DDRESS 1_
WILLIAM A. JENSEN, Sup't of Building
Temple City
BUILDING
.
(IAve
C .
kniar,
FOR APPLICANT TQ FILL IN ROSS ST
E)Escwt-riopt LOT NO. 11 ER
MAIL
BLOCK TRACT ADDRESST7
NO. 01' BLOGS.
SIZE OF LOT NOW ON LOT C:TY
er-i-1)1 e 0- 721,
6!5-E OF S
BUiL.,.G. ReSidence DISTRICT NO. GROUP� MAP PROCESSED BY
P.
CONTRACTOR,...'
ADDRESS CONNECTION DATA
mp
CITIfSTATION DEPTH
1 `kt A.9
STATE MANHOLE RFFERENCE -1
L11 W ER.
REG;STRAT12 5 COUNTY -
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
I'OUSE SEWER CONN ECI ING TO Y. CURB
TO P.L.
PUBLIC SKWFR S5.00 P ,NO.
SEPTIC TANK.SE�EPAGE PIT OR JOB NO.
A11D/OR DRAINFiELD Co.IMP.Na., Q
qous-F-ti "V E R CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $3.00 1
WAIVER EA�31IM�4T RECORD.INSTIR
--CONNICT ADDITIOKAL.BL6'- N�, DATE
1 OR
WORK TO HOUSE SEWER @ 53-00
OV RLE
OW SEEPAGE PIF.DRAB FIELD
EX;N
..CE5SPC)OL,DRYWELL,MANFIOLE @ $5.00
HWY.OR ST.WIDENING
R
-
ALTE ,REPAIR OR ABANDON HOUSE
-SEWER OR DISPOSAL SYSTEM $3.40 STATE ENC R OACHMFNT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OwNtES-7 PERMIT CHARGES
00
AUTHORIZATION CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- RE;MBO SEMENT FEE-R
TRAC(OR TO CONINFCT THE ABOVE DESCRIBED EXISTING OWELLiNG
-11-$--I---r-T-O L".S-IGNA-T-UR-E
T I DATE
�O TF PUBLIC SEWER. APPROVALS
SIGNED THIS-----DAY
OWNER OR NEW HOUSE SEWER
OWNERS CON-N.ECT-A-D-D-ITIONAL.
ADDRESS B U iLD!NG OR WORK
SFPTiC TANK,SEEP,PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
E)
N
A 'STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WIT#i ALL. COUNTY ORDjN'ANCES AND STATE LAWS REGULATING
M15 ING AND YWr
FLU SEWERS: CESSPOOL OR �LL ❑
HEREBY C.eRTIF-Y THAT- I AM. PROPERLY REGISTERED' AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS,REQUIRED BY LOS ANGLES COUNTY AND 'STATF OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT fr'AM THE LEGAL.16r*IER OF,
F, AND INTEND TO D,SCONNECT PLUG AND f
RESIDE 1 1 ,"rHE ABOVE DESCRIBED R� NTIAL� PROPERTY. ABANDON HOUSE SEWER
SIGNATjjR.E ✓
OF PeRmrrT E:- BACKFIL,S E PTIC TANKS
SEEP,PITIS) CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
C K, M.O. � CA.11