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CES08.8.38 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING o�
JOHN A. LAMBIE, Couaty Fmgiaeer ADDRESS /%
CASSATI' D. GRIFFIN. Sup't of Building LOCALITY % n
- NEAREST
LEGAL FOR APPLI T TO FILL IN ceoss ST.
DESCRIPTION LOT N0. 7 OWNER {'Z�l V�
BLOCKTRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL,NO.
USE OF
BUILDINGS _ ^ t^ � DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESSyIC.+ �9�!/, ✓>'i-�,��iii� ���,J C NNECTION DATA
CITY 7 � EL.N0. .j. i STATION DEPTH
H/STATE MANHOLE REFERENCE 9 U
REGISTRATION NO. / ❑ COUNTY LO ER
NO. DESCRIPTION OF WORK FEE `
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00T E OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $8.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. C-7
PRIVATE DISPOSAL SYSTEM Q $1.00 CO.IMP.NO. 4a'_N0. /
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. -.
WORK TO HOUSE SEWER Q $1.00
ALTER, REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVVNER'wS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE d3t-> 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 SEWER. 2 �-
SIGNED THISNEW1`JLS� NEW HOUSE SEWEROWNER OR OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
AHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[3- DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT(A ROPERTY.r f19 BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTE
®e ALMATION ROBERT A.WOOD
gu,
X.O. OAgR SUPERVISING MECHANICAL ENGINEER
( ACO 7 3 9 8� r��. � � � � 5.00 �'