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7APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING i
JOHN A LAMBIE County Engineer ADDRESS 3
WILLIAM A JENSEN Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO ,�j� OW NE
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS / DISTRICT NO GROUP MAP PROLE ED BY
� BK PG r
CONTRACTOR
ADDRESS CONNECTION DATA
C V TEL NO Q STATION DEPTH
�7 I}��7��TATE ///��y PPER
REGISTRATION NO �� LJ COUNTY MANHOLE REFERENCE
NO OESCRIPTI N OF WORK FEE TYPE OF N LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO 1231
JOB NO
PITS AND/OR DRAINFIELD @ S1000 O
HOUSE SEWER CONNECTING TO —^
PRIVATE DISPOSAL SYSTEM @ $300 TRUNK PERMIT NO ROAD PERMIT / � 2 / V
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAtY[a [As[n EMr RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ S300 O
OVERFLOW SEEPAGE PIT DRAINFIELD //
EXTN CESSPOOL DRYWELL MANHOLE $500 LU
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING p.
SEWER OR DISPOSAL SYSTEM @ $300z
STATE ENCROACHMENT N l
PERMIT NO \
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT 2 Oo CHARGES
AUTHORIZATION I TOTAL FEE loe
CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HER IN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE
DWELLING
TO THE PUBLIC SE R O
APPROVALS DATE INSP OSIGNATURE
SIGNED THIS DAY
1 _
OWNER OR NEW HOUSE SEWER
OWNERS AGEN CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP PITS)
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 El
I HEREBY CERTIFY TH I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT/AM TH LEGAL OWNER OF ND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB DESC BED E IDENTIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE G� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATIOI ROBERT A WOOD
`✓J SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LFL 9 9 5 7 FEB 2 4 1 0 D 7 0 0-
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