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76A643-E4 APPLICATION FOR PERMI
76A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE D
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ��+
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITYC+rl
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER /
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. og
rMANHOLE
f
SIZE OF LOT ,a ( OW ON LOT TEL. NO. s
USE OF NO GROU MAP PR CES$ED Y
BUILDINGS ( P _j
CONTRACTOR KCADDRESS CONNECTION DATA
C17Y^� TEL. NO. gqmwT �I DEPTH
❑ STATE REFER CEUPPER
REGISTRATION NO. ❑ COUNER
NO. DESCRIPTION OF WORK FEE E OF CONNEC N LENGTH FR
HOUSE SEWER CONNECTING TO CURB .L. M. ,S0PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR C.NO.
PITS AND/OR DRAINFIELD @ $10.00 NO. OHOUSE SEWER CONNECTING TO ERMIT NO. ROAD PER NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT IVER E115EMINT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
TTABANOON HOUSE HWY.OR ST.WIDENING
SEWER - SY$TEM @ $3.00 STATE ENCROACHMENT y
PERMIT NO.
INDUSTRIAL
la WASTE APPROVAL
CHARGES
WNER'S PERMIT $ 21 Oo
AUTHORIZATION TOTAL FEE -- CONNECTION CHARGE FEE
'IHAVE 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
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIR BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM n
CALIFORNIA OR TH T I AM THE LEGAL OWNER OF. AND INTE
REDE IN, TTO DISCONNECT PLUG AND
SIHE O DES RIBED RESIDENTIA ROPERTY. ABANDON HOUSE SEWER1`G-G� {'�'/'/'T' ,.{./
PERSIGNATURE E BACKFILL SEPTIC TANKS ❑ -v ~�
SEEP.PIT(S) ❑ CESSPOOLS ❑
1 1
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
DK , M.O. CASH
LA C0 9 4 1 2 JUL 3 1 0 D 5.00-
_/51
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