HomeMy Public PortalAbout10258 RANDWICK DR_Sewer__ '6A642D:E80&9-62 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER–SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUf7 y Yom,
JCIF I A. LAMBIE, County Engineer ADDRESS _._.._.—
WILLIAM IL IENSEN, Supt of Building !-n #��-yy g$.
LOCALITY Temple e Ci L
NEAREST
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FOR APPLICANT TO FILL IN CRDs$ T.' Le
LEGAL
DESCRIPTION_ tCiTN is OWNER..._-'dT "r- a.
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TRACT
d� Ci��L�yi�� MAIL
BLOCK _..-_ _ r�s.l.:.da'�--.. ADDRESS
NO. OF SLOGS. .CITY },. ," ,,,,, 0 .y. .}. ff .77
SIZE OF LOT NOW ON LOT �. � `� ��TI&�i. NO. ..: 69 �" C
USE OF' Re
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BU i LDINGS»'�1ti,eSidan Ce DISTRICT NO. GROUP MAP PROCESSED BY
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CC N1 2ACT0
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ADDRESSri+ _IVA CONNECTION DATA
STATION
CITY
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6.. �„ii'g�� m [�
STATE MANHO"E REF LRE^!Cf /� 'PER
R.FGI.S1 RAT 1,40,de� ❑ �OUNT'Y. d � P
NQ, v£SCP PTI-OK OF VVoRK FEE --- - - --' -`- --- - - --
. __ ..-.._ __. !Y FCONNECTIONCURB 7. LENGTH FROM ;
_ � PEO
HpJSE SEW R CC3 TINE T.Nt YO Y. CURB 4.L M.L TQ P L. AL'
PUBLIC SEWER $S.00 _�._._ .' _— PTO _
51:P�IC T'ANh,.>.-EPAGE PIT OR - N �_✓ �.
PITS'AND AOR DRAINf I LD @ ST0-00 CO !MPNO J073-;JO - --
HOUSE—SEWER_.CONNECTING TO4_ I@O
TRUNK PERMIT NO. ROAD PERMIT iT N'D. Q
PRIVATE DISPOSAL SYSTEM 53.00
._ _._ _.- w- _.--__ _. - _.-- _ _ _- __ __-
c_ON NEr7 ADOITiONA BLDG OR AFFIDAVIT i wAiYiR €ASf N.€HT i- REC.OR✓.INST R..NO. DATE
WORK TO HOUSE SEWER @ $3,00
I OVERFLOW SEEPAGE PIT,pRAINFIELD
EX FN.,CF_SSPOOL,ORYWELL.MA NH OLE @ $5.00
.._
Al7ER_.-.R-FPA{R OR ABANDON HOUSE HWY.ON ST WIDENING
�
S F.WER OR Ot'POSAL SY7'vTF.M C� $S.OG' __- - 'TATE ENCROACHMENT
-.-. PERMIT NO. -
-' --------- '--'--- -------"- --f--- INDUSTRIAL
WASTE APPROVAL
___-_ - -... CHARGES
-
OWNEws PERMIT z oo _-- - - — --
----- -- - -_--- _- -� ---- CONNECTION CHARGE FEE,
AUTHORIZATION TOTAL FEE - -- — _ ---
HAVF AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
k:.4c<TOR T'O CONNECT THE ABOVE DESCRIBED EXiST1NG D'VVFLLI,P#G _q�i.-
[O THE PUBL.-:C. SEWER. APPROVALSDATE INSPECTORS SIGNATURE
SIGNED THIS _DAY OF 19__ ------ --- - I __------..._�_
OVY➢O'ER OR NEW HOUSE SEWER
OWNERSAGE NT_T CONNECT ADDITIONAL
new - St
ILOING OR WORK
SEPTIC TANK. F
I-T S'
tDFF.REBY ACKNOWLEDGE THAT i HAVE READ TF15 APPLICATION AND'OR TRAIiFIELD
ANf
STATC THAT THE ABOVE IS COPRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE_ LAWS REGUI ATING
PLUMBING AND SEJ�A_•��RS i; � CESSPOOL [] ORYWELL ❑ '
' HEREBY CER'i`AFY THAT I AM PROPERLY REG.STEREDAREPAIR, -- -i ----�--�-
ANDJOR ALTER, NEWER OR
LICENSED AS. nibu IREm"9Y LOS .ANGLES COUNTY AND"STATE OF SEWAGE:DISPOSAL SYSTEM
CALIFORNIA'of(THAT.Y AM 9HE LEGAL OWNER OF, AND INTEND TOD
RES7.DE 1 xFiADQVE DESC RiBFD REST� ABANDON HOUSE SEWER
NT:A.L PROP'E FFTY.
E ISCONNECT PLUG AICD
S;GNATURF,ef - �' . Y,/ .'� �Y _T--
{ATE ,.-�.,✓' BACKFILL `s EPYICTANKS
❑ _.._I�.._
Or
PERM SEEP,PIT IS) ❑ CESSPOOLS Q
VALIDATION--, ROBERT A. WOOD
' SUPERVISiNQ MECHANICAL ENGINEER
crx. M.O. (c-A H
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