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7D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADORESS 1
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY j✓
NEAREST A y ss
FOR APPLICANT TO FILL IN GROBB ST. 4
LEGAL
DESCRIPTION LOT NO. OWNER ✓ (r(�
MAIL p j•
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY �; TEL. NO.
USE OF p DISTRICT NO. ROUP
MAP "� CESSED BY
BUILDINGS
BK G t
CONTRACTOR J
ADDRESS S ; / DEPTH
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CONNECTION DATA
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CITY s TEL. NO. T- I
SLICENSE, STATION NO. /y �✓ GLA'SS MANHOLE REFERENCE fC' LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CO CTION LENGTH FROM /)
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 C,
SEPTIC TANK.SEEPAGE PIT OR _ ® P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. ! JOB NO. /� V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.Y3"j•!�
PRIVATE DISPOSAL SYSTEM @ $3.00 o O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 (�
OVERFLOW SEEPAGE PIT,DRAINFIELD Lu
EXTN..CESSPOOL.DRYWELL.MANHOLE C $5.00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 7 C>O
IHAVE 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 OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECTADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
TURE
SI OF APERMTTTEE SEEP.P IT(SEP❑ CESSPOOLS S,r�
VALIDATI< �, JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. ASH '
I
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