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76A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS �-7 �Sf�
LOCALITY /I
NEAREST :::C _
FOR APPLICANT TO FILL IN GROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT 7-41 n ADDRESS--3:lr3
NOF SLOGS
SIZE OF LOT NOW ON LOT CITY , TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PS
'CONTRACTOR f -Cz = /2 a .�
ADDRESS< /-� , CONNECTION D
CITY TEL NO c� 16 J9 STATION DEPTH
STATE LIC UPPER
LICENSE NO GLASS MANHOLE REFERENCE
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L
PUBLIC SEWER $7 00
SEPTIC TANK SEEPAGE PIT OR C NO
J
PITS AND/OR DRAINFIELD ® S10 00 CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVES I EASEr EMT RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® $300 Q
OVERFLOW SEEPAGE PIT DRAINFIELD O
EXTN CESSPOOL DRYWELL $500 U
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT O
MANHOLE $7 00 PERMIT NO V
INDUSTRIAL LLA
WASTE APPROVAL Cn
Z
OWCHARGES
OWNER'S PERMIT a cgop
AUTHOREZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE 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 OF _19-
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT tCONNECT
AL o
BU ILDING OR WORK /,/
ADDRESS
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS NGLES COUNTY A-, STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC67N IA OR THAT I AM T GAL OWNER AN9 NTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DE ED RE
ROPE ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEQ MITTEE SEEP PIT(S) SSPOOLS ❑
C2AVALIDATION CK M 0 CASH
4 1 1 C'nFr 22 1 U 0 9.00 113