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APPLICATION76A642D EERMIT� / �
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAM HE. County Eng�11 ADDRES
WILLIAM A. JENSEN. Supt of Building TY�'
_ LOCALI
NEAREST ol
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ®� OWNER 6�/° >�C!�
DESCRIPTION LOT N0.
BLOCK TRACT ��®� MAIL
J� IrP/ y .oV �r ADDRESS
NO.OF BLDGS.
[SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OFDISTRICT N0. GROUP MAP PROCESS $Y
BUILDINGS e' G./ BK PG r
CONTRACTOR !Pp /� //
ADDRESS�!O ,• i ' � �o CONNECTION DATA
CIIT� TEL.NO. STATION DEPTH
REGISTRATION N0. COUNTY MANHOLE REFERENCE UPPER
LOWER
NO. 1 DESCRIPTION OF WORK FEE
HOUSE
OUS ESEWER CONNECTING TOPUBL@ $9.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $8.00
OVERFLOW SEEPAGE PIT.DRAINFIELD 7 d
EXTN..CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO CC 14/P.NO. JOB NO. OU
PRIVATE DISPOSAL SYSTEM @ $1.00
WCONNECT ADDITIONAL OR
TUSSWER @, $1.00 Z O TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. V
W
INDUSTRIAL
WASTE APPROVAL
CHARGES z
OWNERS PERMIT S 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE ®v REIMBURSEMENT FEE
TRACTOR TO CHAVE AT IONNECT THE ABOVS DATE A E DESCRIBED EXWITH THE RSTNNG DWELLNAMED ING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY 1J— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTE14
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS ANG AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA M THE GA NER F THE ABOVE BACKFILL SEPTIC TANK$ ❑
DESCRIBED RESIDE L P OPERTY.
SEEP.PIT(S ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
NNW
VALIDATY� ROBERT A. ICAL E
cK. N.o. cAsx SUPERVISING MECHANICALENGINEER
GOT 5 3 .0
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