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COUNTY OF LOS ANGELES SEWER—SgW ®.A.SP®SAL ; A- ..
' DEPARTMENT OF COUNTY ENGINEER a.
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS _.
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST 4
FOR APPLICANT TO FILL IN j osS ST.
: LEGAL
DESCRIPTION -LOT N0.• OWNER
'BLOCK 'TRACT - 'MAILS
3 - ADDRESS
_ - NO.OF BLDGS..
SIZE OF LOT NOW ON LOT •CITY TEL. NO.,
USE OF • e,,)w .. i a >a:.; ecz'•s-: "-..`... '• ,{•x .
BUILDINGS DISTRT N0 GROUP MAP PROCE ED BY
�1BK, PG '
CONTRACTOR ' (}��" �, I /y ®/ I�•- �
ADDRESS CONNECTION DATA
CITY TEL:NO.., STATION DEPTH
/� STATE "'MANHOLE.REFERENCE
REGISTRATION NO. -,� / �.�/ - •LI COUNTY '•"
a
.NQ. DESCRIPTION OF'WORK FE t:
HOUSE SEWER CONNECTING-TO [���w••` -
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
s SEPTIC TANK;SEEPAGE PIT OR - Y CURB P.Lc M.L.TO P.L.' •P�Lri�
�i .. PITS AND/OR DRAINFIELD @ $3.00.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @.$2.00
'HOUSE SEWER CONNECTING TO A '( P.C.NO: - •�
.PRIVATE DISPOSAL SYSTEM @ $1.00 �CO.IMP. NO. •JOB NO.
CONNECT ADDITIONAL ADDITIONAL BLDG.OR ' - "' - " 0.
-
WORK TO HOUSE SEWER - @ $1.00 T TRUNK PERMIT NO. ROAD PERMIT NO. .S`�� - O
.ALTER, REPAIR OR ABANDON HOUSE 'STATE ENCROACHMENT V
SEWER OR DISPOSAL SYSTEM @ $1.00 ".PERMIT N0 -
. +,
�' Gq
INDUSTRIAL
_ WASTE.APPROVAL - W
.. -
CHARGES. rAA
OVVNER'S PERMIT $ QQ CONNECTION CHARGE EEE '
w:
i AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I 'HAVE-AT DATE ACONTRACT WITH THE.HEREIN_NAMED CON=
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '- APPROVALS ` . DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC'SEWER:'
SIGNED THIS' DAY,OF. 19_' NEW HOUSE SEWEa_
OWNER OR - CONNECT ADDITIONAL
OWNERS-AGENT ,_ $- BUILDING OR-WORK- "• - - — --
ADDRESS - SEPTIC TANK,SEEP:PITS) -
` AND/OR DRAIN-FIELD
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 "-_
PLUMBING.-AND-,SEWERS. SEWAGE DISPOSAL SYSTEM
d 1 HEREBY CERTIFY THAT-1 IAM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND.
LICENSED AS REQUIRED' BY. LOS ANGELES COUNTY AND STATE.OF ,-DISCONNECT
HOUSE SEWER '
- -'
CALIFORNIA OR THAT AM THE LEGAL 'OWNER OF THE ABOVE _
-DESCRIBED-RESIDENT PROPERTY. - BACKFILL SEPTIC TANKS,❑ '
SIGNATURE"
; SEEP.PIT(S) ❑_CESSPOOLS ❑ _
OF PERMITTE - - -
,.Y
®r
VALiDATIO 'A ROBERT WOOD
,_ .SUPERVISING MECHANICAL.ENGINEER . ,
• _ "CK.�. ".. M.0. ... CASH... .. .. `' -
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