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CE808361 APPLICATIONFOR p RM T
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL - AnOWNER ,
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS HK PO DISTRICT NO GROUP YAP P CE ED BY
CONTRACTOR �� D
ADDRESS/-I CONNECTION DATA
CITY TEL NO .3—7 ON DEPTH
// COUNTMANHOLE REFERENCE D PP
REGISTRATION NO [O Y J
No DESCRIPTION OF WORK FEE
PUBLIC SEWER CONNECTING TO @ $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD S3 00 Y CURB P L Y L TO P L
OVERFLOW
EXTNC SEEPAGE PIT @ $2 00 a
HOUSE SEWER CONNECTING TO / P C NO O
COPRIVATE DISPOSAL SYSTEM @ $I 00 IMP NO JOB NO L)
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER S1 00 TRUNK PERMIT NO ROAD PERMIT NO ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT O`
SEWER OR DIS SA Y TE @ $100 PERMIT NO ()
ov INDUSTRIAL ILW
WASTE APPROVAL V)
N
CHARGES Z
OWNERS PERM $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
HAVE AT THIS T ACTOR TO CONNECE E0 ABOVE ESCRIBED EXISNTRACT WITH THE NG DWELLN NAMED ING APPROVALS DATE INSPECTOR S SIGN4TURE
TO THE PUBLIC SEW
SIGNED THISDAY 19— NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL
OWNERS BUILDING OR WORK
ADDRES SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
LDESCRIBED
HEREBY ACKNOWLEDGE THAT t HAVE REA THC$ APPLICATION
D STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
UMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
ENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
LIFORNIA OR THAT 1 AM T EGAL 0 R OF E ABOVE BACKFILL SEPTIC TANKS ❑
RESID I 0 Y
NATURE SEEP PIT(S) CESSP00
F PERM ITTE
VALIDATION ROBERT A WOOD
M 0 c"R SUPERVISING MECHANICAL$NGINEER
5141% OCT 411D 2500- d
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