HomeMy Public PortalAbout10233 RANDWICK DR_Sewer__ 171 W,.,
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'13A6362
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6A84APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION AB�oREs O '�E " ck
JOHN A. LAMBIE, County Engineer ---------------- ------
WILLIAM A. JENSEN, Sup't of Building LOr_ALITe ti s'"I ;3s w Clty-
..NES-RES: \Y �d 1a.:•;..��_i� 1r
FOR APPLICANT TO FILL IN CROSS ST.
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DESCRIPTION LOT NO V v OWNER ��34�"til f,..i .` 4 s
BLOCK TRAC:7 F.',p +''�.3 iJ ADDRESS ,�2`
MAILii c"7 • .Sr w/- -d> t'.' I
.M'v�". t'71- --
._______
NO. OF BLDG :"t''GA n.�l
3,k1 fi
SIZE OF L.03' NOW ON L0� CITY TFL. NO.
BUILD I NGS �8'�L er DISTRICT NO. GROUP MAP PROCE55ED BY
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CONTRACTVRy. Cry �('y'�,� �� - p '`yam F,�' , i !✓� G I
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ADDRESS-- ` " ._._ € CONNECTION DATA 1 7 ---
'ti. �^ - 8 TAT+Or ,y- - ---
CITY- SO w .:,Tan �9 b,,:91 1 �{j. y DEPTH
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77
STAT: -ANHIaLE RE'F-11EPaCE
REG STRATIO - COUNTY i h +, -�.+ FLOW ESt
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NO CIESCRS PYLON OF WQRk FEE _ 'TYPE OF CONNECTION LEI+IGYH FROM
HOUSE SEWER CONNECTING TO i Y
PUBLIC S _-_5_--_�.-_- _ CUR
B � PL MJ_TO P.L.
EWER �
ldP C.NO.EPTIC TAMC SEEPAGE Pi'T OR -- Co. 'MP NO. JOB NO
�.I P47S ANLL:cm DRA!NFIE'LD Com' r
§40.00 I j _.. _ I.__ -__.___ - _._-__ _.._..__.-_- _._� _.G...- _
NOL SEIVER CON NECT ING TO TRUNK PERMIT N6 ROAD PERMIT NO. gy
PR".4TDISPOSAL SYSTEM @ 53.00 O
5----
CONNECT ?,DD ITIONAL BLDG.-OR-_ - -IT-�-- AFFIDAVIT wAi'r[I, kASEMfu T RECORD-CN- NO. DATE
WORK TO HOUSE SEWER @ $.3-00
-_ _.___
OVERFLOW SEEPAGE PIT,DRAINFtELD I '
EXTN CF SSPOOL,DR{W'ELL,MANHOLE @ $5.00
HWY.OF ST.WIDENING
1 ALTER,REPAIR
_OR__ABA NDON Fq OUSE
�.;
SEWER OR DISPOSAL SYSTEM @ SS-00
_-__-.
_.. STATE.ENCROACHMENT
PERMIT N-1,
INC STRIAL
WASTE.APPROVAL
OWNER`S PERMIT
— -----—
C,HAPCES
00
AUTHORIZATION TOTAL FEE / CONNECTION CHARGE FEE
+Ay.
I HAVE. AT 7E-115 DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMLUR £MENT�FEE
'TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTI h4G DWELLING ------ - - - r-- - -- --- '----
TO THE PUBLICSEWER. APPROVALS DAT_ _{I N5PCCTOR5 SIGNATURE
SIGNED THIS--- DAYOWNER OR �' NEW HC>la Sf Sc'..WER
O
OW PIERS ACTEN7-_____ _^ CONNEC. ADDITIONAL
Bull-DING-OR WORK,
ADDRESS _
5,?TIC TANK.SEEP,PIT(S) ,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR D AINFIFLD '
AND STATE THAT THE AF30VF IS CORRECT AND AGREE TO COMPLY
WITH Ai_L COUNTY ORDINANCES AND STATE LAWS REGULATING I
PLU 1/,SING AND SEWERS. C.EESSPOOL
_.. [-j DPYW ELL �}
I HEREBY C FRTIF'Y,THAT '1 AM PROPER+Y REGISTERED AND/11 ALTER,REPAIR,SEWER OR
CENSED IAS REQUIRED BY LOS ANGLES COUNTY A.ND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM 7HE LEGAL OWNER OF,-AND ENTEND T'O _-____ .__._L--
DISCONNE T YUC AND
RES.iDE IN, THr ABOVE DESCRIBED RESIVAT1AL.'PROPFRTY.
ARAN DC'N HOUSEEWEI
SIGNATURE,' ___-R _- ____
.A _,,,�:, 'r �KBACKFILL SEPTIC TANKS i� --_-
OF PE RMATT'«E' } - _ _ _
SEEP.PiT(S) [f CESSPOOLS ❑�
r VALIDATIONROBERT A. WOODE:
v SUPERVISING MCHAWCAL ENGINEER
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