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76A646A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. '
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OPFBLDGS.
SIZE OF LOT �v NOW ON LOT CITY , TEL. NO.
USE OF
BUILDINGS
DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR ( Cy L L-
ADDRESS j CONNECTION DATA
,P� STATION DEPTH
CITY TE . NO. J
❑ STATE UPPER
REGISTRATION NO. [ICOUNTY MANHOLE R\ ERENCE
LOWER
NO. DESCRIPTION 01�7_WORW FEETYPE OFC NNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C B P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER I EASE MEN RECORD._FN STR.N0. DATE
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
OR ABANDON HEYtJSE p( HWY.OR ST.WIDENING N
DISPOSAL SYSTEM @ $3.00 >J STATE ENCROACHMENT
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE L) V\t
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING v
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 I AM THE EGA OI N R , AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB VE S ED 'S AL ROPE RTV. ABANDON HOUSE SEWER 02
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS r
SEEP,PIT'S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK. M.O. GASH
SUPERVISING MECHANICAL ENGINEER
";I10 1 0 9 2 "P" 3 0 1 10 D 5.0 0 s