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CE808 3 62APPLICATION FOR PERMIT
76A642D 642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING rp�
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICA T TO FILL IN CROSS BT
LEGAL
DESCRIPTION LOT NO Q� OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY C _ TEL N04-77 *70 !r16-
US
E OF 'rte DISTRICT NO GROUP MAP PR ESSED BY
BUILDINGS C S f
B++K PG / JJ
CONTRACTOR � �' � O
:AADDRESS y �,� C CONNECTION DATA
CITY TEL NO Q STATION DEPTH
I
REGISTRATION NO LJ COUNTY
MANHOLE REFERENCE UPPER
NO I DESCRIPTION OF WORK FEE TYPE OFTION LENGTH FROM
HOUSE SEWER CONNECTING TO -� Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 p NO
C
SEPTIC TANK SEEPAGE PIT OR CO IMP NO P C NO V
PITS AND/OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO j 3
PRIVATE DISPOSAL SYSTEM @ S300 I
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXT N CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 7
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT b•
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY O tg_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT M PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED B LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A.
SCRIBED RESI TIAL OP TY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION
SH ROBERT A WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER
LAI' 1 2 5� n}�� 1 7.00 s