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76eo e,;a APPLICATION FOR ERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Fmgiaeer ADDRESS �J O
CASSATT D. GRIFFIN, Sup't of Building LOCALITY
NEARES
FOR APPLICANT TO FILL IN CROSS Of 21�e
LEGAL ry
DESCRIPTION LOT NO. OWNER ( -�
BLOCK TRACT MAIL
L ADDRESS
0.OF BLDGS. 3
SIZE OF LOT NOW ON LOT CITY TEL.N0.
USE OF
BUILDINGS DISTRICT NO.1 G8.Q0 MAP PR CESSED BY
CO 1 - eBK PG,
ADDRESS ' CONNECTION DATA
CITY TATION - DEPTH
8 STATE
N N0. COUNTY MANHOLE REFERENCE UPPER
GISTRATIO � 7
NO. DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENG H FROM
PITS AND/OR DRAINFIELD @ $3,00 Y. CURB - P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 / !!
OUSE SEWER CONNECTING TO P.C.N6.
IVATE DISPOSAL SYSTEM @ $1.00 CO. P.N0. JOB N0.
14
ONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 Do. CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ! REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWE n
SIGNED THIS Y OF 19_ NEW HOUSE SEWER /'r''�( !�
OWNER OR CONNECT ADDITIONAL _ V
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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
PLUM ING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I EREBY CERTIFY THAT I AM PROPE REGISTERED ND/OR DISCONNECT PLUG AND
LI NSED AS REQUIRED B LOS ANGE COtf Y AND ATE OF ABANDON HOUSE SEWER
C LIFORN OR THAT 1 THE LE L OWXE OF ABOVE
D RIB ESl ENTIAL OPERTY. BACKFILL SEPTIC TANKS❑
bV t SEEP.PIT(S) ❑ CESSPOOLS❑
G 4 0
RMIT F
®r VALIDATION ROBERT A.WOOD
U.p, CMM SUPERVIHING MECHANICAL ENGINEER
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