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76A642 0-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADORE
JOHN A LAMBIE County Engineer B
WILLIAM A JENSEN Sup t of Building
OE FOR APPLICANT TO FILL IN V ��
LEGAL rr DESCRIPTION LOT NO OWNER M/MAIL LBLOCK TRACT ADDRESS
NO OF EL0GS ,�//SIZE OF LOT NOWON LOT CITY {+ #//� EL NO USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR
ADDRESS ,�-oZ0 CONNECTION DATA
� '�/7 STATION f- DEPTH
CITY TEL NO / (J
❑ STATE / UPPER
REGISTRATION NO ❑ COUNTY MANHOLE REFERENCE /
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEN H FROM
1 HOUSE SEWER CONNECTING TO Y CURB L M L TO P L
PUBLIC SEWER @ $5 00 O
SEPTIC TANK SEEPAGE PIT OR 7 P C NO
PITS AND/OR DRAINFIELD @ S10 00 / JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ix
PRIVATE DISPOSAL SYSTEM @ $3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO
WORK TO HOUSE SEWER @ $300 3V•
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ S5 00 d
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF - 19_
OWNER OR rI ` NEW HOUSE SEWER
OWNERS AGENT Sy(� CONNECT ADDITIONAL '
BUILDING OR WORK
ADDRESS L
SEPTIC TANK SEEP PIT(S)
1 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 ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS 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 DESCRIBED RESIDENTIAL PROPERTY gBAN DON HOUSE SEWER
SIGNATURE J�)�1- BACKFILL SEPTIC TANKS ❑
OF PERMITTEE � - SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A wood
'\ CK M o CASH SUPERVISING MECHANICAL ENGINEER
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