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" 864 0 63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU ILDI NG
JOHN
JOHN A. LAMBIE, County Engineer ADDRESS G - t—
WILLIAM A. JENSEN, Sup't of Building
LOCALITY �
NEAREST
FOR APPLICANT 70 FILL IN CROSS ST.
LEGAL i
DESCRIPTION LOT NO. OWNER tr-V�•/�f
/ MAIL
BLOCK TRACT L' ADDRESS
NO. OF SLOGS.
SIZE OF LOT 1,0 NOW ON LOTqAETY
TY TEL. NO.
USE OF STRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
j BK PG
CONTRACTO 4, // ,,
ADDRESS CONNECTION DATA
ATION DEPTH
CITY TEL. NO.
NHOLE REFERENCE <REGISTRATION NO. �A) c/G�NO. DESCRIPTION OF RK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB .LM.L.TO P.L.PUBLIC SEWER 55.00
P.C.NO.SEPTIC TANK,SEEPAGE PIT OR .IMP.NO. JOB NO. / O
PITS AND/OR DRAINFIELD a E10.00 U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 0 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIvcR [ASFML NT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD UJ
EXTN.,CESSPOOL,DRYWELL,MANHOLE $5.00 DL
ALTER,REPAIR OR ABANDON HOUSE HWY,OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT Z
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER$ PERMIT s 2 00
AUTHORIZATION I TOTAL FEE 7
f/) CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
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
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT qND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED B LOS ANGLES COUNTY AW STATE OF SEWAGE DISPOSALSYSTEM
CALIFORNIA OR THAT I THE LEGAL O R OF, 1 TEND TO DISCONNECT PLUG AND
RESIDE IN, THE AS ESCRIBED RE TIA P OPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS EIOF PERMITTE SEEP, IT
(S) ❑ CESSPOOLS ❑ �",_±�J yrs -) ��
VALIDATIO ROBERT A. WOOD
CK. 14.0.
SUPERVISING MECHANICAL ENGINEER
CASH
1 21 1 AX 13 1 0 0 7.00-
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