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CE909989 APPLICATION OR PERMIT - 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A IIMBIE CountyEa ADDRESS
giildm
CASSATY D GRIFFIN Sup t of Build�ag LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL '
DESCRIPTION LOT NO O OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP BK MAP PROCESSED BY
CONTRACTOR'] �G/
ADDRESS� CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFERENCE PPER
REGISTRATION NO COUNTY �1�Z R
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION EENTH FROM
PITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P-IP
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P CO
PRIVATE DISPOSAL SYSTEM Q $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO as
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERIM $ 2 00 CONNECTION CHARGE FEE 4
AUTHORIZATION I TOTAL FEE !!5- JC6 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR y S�ONATURE
TRACTOR TO CONNECT IiF'A86 DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWF \
SIGNED THIS DAY I9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEGAL 0 NER OF THE ABOVE
DESCRIBED RESIDENT OPERTY ACKFILL SEPTIC TANKS❑
SIGNATURE SEEP P (S) ❑ CESSPOOLS
OF PERMITTE
®r VAI.IDATION,---'-% ROBERT A WOOD
CK x o CA2R SUPERVISING MECHANICAL ENGINEER
t '9 1 0 6� �t)L , 0 A Jc {) 0 t1l,