HomeMy Public PortalAbout10228 RANDWICK DR_Sewer__ Til-1-7-OL11" CII
;E,308 3-E2
'BAF 420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU FLO?NG
B I
W10FADDRESS
LM A.ALAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building
LOCALXTY
C
NEAREST
OSS
FOR APPLICANT TO FILL IN CRS
AL
DESCRIPTION LOT NO. OWNER
MAIL n- e-
r
BLOCK TRACT DDRESS
5926--Ta..
NO. OF B LDGS.
SIZE OF LOT NOW ON LOT NO.
US' OF
DISTRICT NO. GROUP MAP PROC95SED BY
BU[LDINesidence
BK PG
CONTRACTPIR
ADD RESSZ,24Z CONNECTION DATA
TkT
CITY STATION DEPTH
STATE
REG ISTRA":15.2 5 D COUNTY MANHOLE REFERENCE
0 WER
N-0.
TYPE OFCONNECTION LENGTH FROM
HODS S>*W£N CONNE(,TING 70 Y. CUKB
PUBLIC SEWER PA- M.L TO P.L.
;� ----- 0
SF LANK-1 6E-EP-A7GE 0vT-67R------ C"'O.
S IC 10S NOFITS .
@ $10.00
CO.IMP. NO.
ANC OR GRAINFIELD
OUSE
SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
P
RIVAYE DiSPOSAL SYSTEM @ $3,00 0
4--- -
$3.00 AFIMANIT
- -- ,R—--- - ---- -
CONNECr
T ADDITIONAL BLDG.OR @ I� WATV� DATE:
___._1-WQRK1QHOIjSE-SEWER--
OVERFLOW SEEPAGE PIT,ORAiNFIELD
E X I N�., ESSP
_?OL,DRYWFLL, AI
MNHO _E_�_
-r
ALTER.REPAIR 0 R_ABANDON_HOUSE HWY. OR ST.WIDENING Zz
OR DISPOSAL SYSTEM $3,00
SfATIE ENC;iOACHMENT
PERMIT NO.
INDUSTRIAL
WASTE AFPROVAL
CH R.HG ES
OmmRPERMIT 2. 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I
Z"
I HAVE AT THIS DATE: A CONTRACT WITH THE HEREIN NAMED CON_ R.Elf-MBURSEMENT FEE
TRACT'DR. TC1 CONNECT THE ABOVE DESCRIBED EXI�!TIN C,; OW ELL,?N_q
TO THE PUPLIC SFWAPPROVDATE RUR
ALS
E::, INSPECTO 'S SIGNATE
SIGNED THiS------DAY OF--,-_-19_
OWNER OR NEW HOUSE SEWER.
OWNERS AG5N T---
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEEP,PTT(S)
I PrItrey4CK NOWLEDGE THAT i HAVE READ THIS APPLri'AT'ON ANPI/OR 0RA)NFIrLD
AND STATE THAT THE A,80YF IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ,ORDINANCES
AND STATE LAWS REGULATING
PLU MaIN G AND CESSPOOL L OR
I HEREBY CErTtFY THAT I AM PROPERLY REGI$TrRD ANDl SEWER REPAIR, EWER OR
. F
LICCNSED AS,,REQUIRED BY LOS ANGLES COUNTY ANO STATE 05 SEWAGEOISP05AL SYSTEM
`ALWRNIA,'�,�ik THAT I AM THE LEGAL qWNFR OF, AND INTEND 10 -&fsc Nzc'r PLUG AND
Ra sI D., ;N,,AHr. ABOVE DESCRIBED ;ftNTIA
E
, X P-56PERTY. ABANDON HOUSE SEWER
! !�K ,
A T V qik
OF PE D CESSPOOLS Ll RACKFILL SEPTIC TANKS [71
k, "- , SL EP.PIT{51 i
/ VALIDATIONROBERT A. WOOD
CK. M 0 &AS'._ SUPERVISING MECHANICAL ENGINEER