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S&E-663 11.55 APPLICATION FOR PERMIT 1
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39VISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT of BUILDING
LOCALITY
NEAREST •6�-
FOR APPLICANT TO FILL IN CROSS ST. �
LEGAL OWNER
DESCRIPTION LOT NO.� ,f �/
MAIL
BLOCK TRACT _ ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY fL L. N0.
USE
BUILDINGS DISTRICT NO. GROUP MAP
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CONTRACTOR 3- ,�K-
ADDRESS
X CONNECTION DATA
Ll S `' j� . �• � � 7 ,� /
CITY ,M 4� TEL. N0. `` 3 STATION DEPTH
V �� ~ MANHOLE REFERENCE UPPER
/ -STATELOWER
REGISTRATION N0. / �� ❑ COUNTY -S-74 ad eC J C ,N
No. DESCRIPTION OF WORK FEE T
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO
Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50 Q
SEPTIC TANK,SEEPAGE PIT OR /7 ��Of-d x� S•t� �J '� rt�
PITS AND/OR DRAINFIELD @ $3.00 / D
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
EXTN.,CESSP00L,DRYWELL,MANH0LE @ $2.00 CO. IMP. NO. // !OB NO.
HOUSE SEER
PRIVATE DISPOSAL SYSTEMG TO @ $1.00 TRUNK PERMIT NO. �If7� ROAD PERMIT NO./OD 2S
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER $1.00 _ PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE IREIM
SEWER OR DISPOSAL SYSTEM @a $1.00 PPROVAL
CHARGES
ION . Y.
OWNER'S PERMIT $ 1 00
SEMENT FEE
AUTHORIZATION TOTAL FEE E"1
I HAVE AT THIS DATE A CONTRACT WITH THE HER NAMED CON- PROVALS E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER �� •,��`.1r*.'
SIGNED THIS DAY F 19- CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLED THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I Aft THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL 'OPERTY, BACKFILL SEPTIC TANKS❑
SIGNATURE \ SEEP.PITS) LlCESSPOOLS_❑
OF PERMITTEE,. ~� Y
JOHN A. LAMBIE, uNTY ENGINEER ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
oVALIDATION
Y.O. CASH
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