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COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING %
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
REIM NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT , l .. MAIL
ADDRESS
N0.OF BLDGS. [rte
SIZE OF LOT Z NOW ON LOT y' CITY TEL. NO. �J
USE
BUILDINGS DDISTRICT NO. OUP MAP PROCESSED BY
,���
BK PG
CONTRACTOR / �G
ADDRESS ) l COLN—NECTIONOODATA
CITY TEL.N0. ° STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTIO OF W K FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. '
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. MP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO.
WORK TO,HOUSE SEWER @ SLOO
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $t.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE'AT DATE A CONTRACT WITH THE HEREIN I(TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLING APPROVALS. DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. per
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER (�
OWNER OR �,,�e-� CONNECT ADDITIONAL;/
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.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 ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 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 LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PRO ERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE - SEEP.PIT(S) .❑ CESSPOOLS ❑
OF PERMITTE
OF VALIDATION
ROBERT WOOD
CK. M.o. CASH SUPERVISING MECHANICAL ENGI EER
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