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76A642D APPLICATION FQ® OG® VIT l�
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDREss
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL O!
DESCRIPTION LOT NO. / OWNER •��"� ,,,,_// IIIj"', fI�•
MAIL v
BLOCK TRACT (' yCs a,. ADDRESS
NO. OF SLOGS. [�
SIZE OF LOT 0�9//t?(�
+ NOW ON LOT CITY f i.•"rEL. -NO. (
USE OF
BUILDINGS -DISTRICT NO. GROUP MAP CE5SED BY
BK PG
� p � � -
CONTRACTOR /1 �(,i
ADDRESS ;sO �,'- - t ��,-• CONNECTION DATA
CITY •1^— ,TEL. NO.I `� 7 STATION S�- -7 DEPTH
Ej STATE
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE E
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ' LENG FROM��
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER a $5.00
SEPTIC TANK,SEEPAGE PIT OR / P.C.NO. }
PITS AND/OR DRAINFIELD S10.00 - CO.IMP. NO. JOB NO. OL
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG,OR =IV9R I EASEMENT RECORD. INSTR.NO. DATE 04
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENINGCL
LV
SEWER OR DISPOSAL SYSTEM $3.00 to
STATE ENCROACHMENT
PERMIT NO. Z.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE 7 li2o 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 SEW Ry �O'L- APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS 1' DAY OF '49 19�V`
OWNER OR t//� NEW HOUSE SEWER
OWNERS AGENT - T/"I /
CONNECT ADDITIONAL
ADDRESS / ij's BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DEED/RESIDENTIAL PROPE Y. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
❑
SEEP,PIT(S) ❑ CESSPOOLS
ALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
' 6357" OCT 13,10 A 7.00 `