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76A642 A! pLICAT ON FOR PERMIT
76A64260
SEWER-,SEWAGE DISPOSAL ,
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �/o l
ADDRESS
JOHN A LAMBIE County En neer ~
WILLIAM A JENSEN Sup t of Building LOCALITY /
NEAREST
FOR APPLICANT IN CROSS ST
LEGAL r
DESCRIPTION LOT NO {OWNER
BLOCK TRACT MAIL
ADDRESS.. s t
NO OF BLDGS ` ~
SIZE OF LOT yy NOW ON LOT CITY TEL NO
USE 0BUILDINGS GAS DISTRICT NO YT
MAP P CESSED BY `�
BK PG I
CONTRACTOR O C �"
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ADDRESS f ` ONNECDATA
C17Y ^'TEL NO ,6 STATION 3 DEPTH
STATE
REGISTRATION NO 1616)-5 6 Z- L.J COUNTY MANHOLE REFERENCE
� / LO ER
No I DESCRIPTION OF WORK FEE
SEWER CONNECTING TO
C SEWER @ $3 00 LENGTH FROM
PITS AND/OR D SEPTIC TANK EEPAGELDT OR @ $3 00 Y CO B P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
e HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO a y�
CONNECT ADDITIONAL BLDG OR W
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO V
ALTSEWER REPAIR
SYSTEM R ABANDON HOUSE @ $1 00 STATE ENCROACHMENT N
PERMIT NO r 0
INDUSTRIAL 8
WASTE APPROVAL W
CHARGES z
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE Fi
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEEIHAVE AT > v v
S DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING -APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DQ�OF �- 19_ `NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK-,ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION T t a
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ + C�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 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 1 AM THE LEGA OWNER OF THE ABOVE
DESCRIBED RESIDENTI L PR PERT BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
®P ALWATION ROBERT A WOOD
TSUPERVISING MECHANICAL, ENGINEER
CIC H 0 CASH ._.
Irl L-,3 4 b 5n 0 0 I'
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sab(019NSE kfs`
CE6066.60 APPLICATION FOR PERMIT
�6Afiazn COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS !/
BUILDING I�7 /le—
JOHN A. LAMBIE, County Engineer ,
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLI/C] TO /L CROSS ST.LEAL
DESCRGP ION LOT NO. ZCr. OWNER 7
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY TEL. N
USE OF
BUILDINGS S T /c BK P6 DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR /! ,,/
� / 'r� 7— � c�L
ADDRESSf� �Y CONNECTIO ATA -....
CITY/17, STATION
&OZW,tK1
L; STATE MANHOLE REFERENCE
REGISTRATION NO. �/�� / COUNTY
LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO =�
PUBLIC SEWER Cv A-00 TYPE OF CON C LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. C P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD@ 4.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ 4.00
HOUSE SEWER CONNECTING TO P.C.NO.
_ PRIVATE DISPOSAL SYSTEM @ $1 00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. U
_ WORK TO HOUSE SEWER @ $1 00 �r.�
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT a
SEWER OR DISPOSAL SYSTEM @ $ .00 PERMIT NO. O
INDUSTRIAL L)
_WASTE APPROVAL w
P.
CHARGES rn
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 10D REIMBURSEMENT FEE
IHAVECON-
TRACTORATO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT THE IINGAMED DWELLIING APPROVALS DATE I NSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS CD Y OF-- 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK.SE EP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
L
COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT I AM THE LEGAL WNER OF 'IHE ABOVE
RESID TIA PROP RTY. BACKFILL SEPTIC TANKS ❑
E SEEP.PIT(S) CESSPOOLSiITTE '
®r VALIDATION ROBERT A. WOOD
CK. H.0. CASH SUPERVISING MECHANICAL ENGINEER
J 7,
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