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i=808 11-57 G 9 APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ss� /
JOHN A. LAMBIE, County Engineer ADDRESS J �� r rit'/1�f
CASSATT D. GRIFFIN, Supt of Building
LOCALITY /Ynl2 -� 4 61/
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL L \ /
DESCRIPTION LOT NO. \/ '��� OWNER 21"� ✓ t
BLOCK TRACT , l GT tY'- MAIL l
ADDRESS -
^ NO.OF BLDGS. �I
SIZE OF LOT SCG' 0 NOW ON LOT_ CITY TEL.NO.
USE OF /J� ..:..... ....,
BUILDINGS �-•.J ' << DISTRICT NO. GROUP MAP
CONTRACTORf �• L•�J•^"��I I BK PG
Ll
ADDRESS CONNECTION DATA
CITY TEL.NO. /� STATION DEPTH
STATE/�j"(J �J /'�/� ❑ COUNTY MANHOLE REFERENCE
REGISTRATION N0. LOWER
No. DESCRIPTION OF ORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER e° ®� TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. URB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXT N.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP.NO. ® JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.'�
ALTER,REPAIR OR ABANDON HOUSE 0 If
SEWER OR DI POSAL SYSTEM 14 @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE (5)6REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• y,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS /` DAY OF 92 19 a�� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL -
OWNERS AGENT -tom BUILDING OR WORK
ADDRESS - - -SEPTIC TANK,SEEP,PIT(S) - -
AND/OR DRAINFIELD
I HEREBYLA KNOWLEDGE THAT I 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT .1 AM PROPERLk�RISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES AND SATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT /AM THE LE L OF.. T ABOVE ABANDON HOUSE SEWER .4
DESCRIBED RESIDENT L-PROPERTY. BACKFILL SEPTIC TANKS ❑SEEP.PIT(S) ❑CESSPOOLS F]SIGNATURE _ , /
OF PERMITTEE-
OF VALIDATION ROBERT A. WOOD
CK. M.O. CAS SUPERVISING MECHANICAL.ENGINEER