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76A642D APPLICATION IZ PERMIT
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 �- `�U'►' '�'�-.9L
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
�1. MAIL
BLOCK TRACT r- ADDRESS
NO. OF BLDG S.
SIZE OF LOT NOW ON LOT � CITY
USE OF �_6 r Y DISTRICT NO. GROUP MAP PR SSED BY
BUILDINGS BK PG
CONTRACTOR�Z—)TeA
ADDRESS �T� �/ f y _ �•7 CONNECTION DATA
I/. ✓ �NO. -`�
CITY STATION _L � DEPTH f
'�� �U(:r TEL.
STATE
COUNTY MANHOLE REFERENCE �� UPPER�I
REGISTRATION NO. R
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F OM /) /
y HOUSE SEWER CONNECTING TO Y. CURB .L. ) M.L.TO P.L. �y,[
! PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR / P.C.NO. >_a p��
PITS AND/OR GRAINFIELD $10.00 JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD F'
EXTN.,CES SPOOL,DRYWELL,MAN HOLE @ $5.00 HWY.OR ST.WIDENING UJ
ALTER,REPAIR OR ABANDON HOUSEiL
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT h
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OWNERCHARGESS PERMIT S s oo ,
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �''
'iHAVE 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 1 e 'd.n /J
'gri�1,( _ „/n i w i`�/! .�,,.�J'/4• NEW HOUSE SEWER
OWNERS AGENT L/ dam'— � �`�" h P1"° CONNECT ADDITIONAL
Lf
ADDRESS ✓ '�'r?L r BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL 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 DF&CRISED,lRREESID/EENSIAL PROPER Y. ABANDON HOUSE SEWER
SIGNATURE a 1 ss,�f � {i` •//r Y�o�J , BACKFILL SEPTIC TANKS ❑
OF PERMITTEE .: { A'vv�lll /� li�✓Q�`"1 SEEP,PIT(S) ❑ CESSPOOLS Cl
/VALIDATION ROBERT A. WOOD
Ivy, SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LJICO 9 2 5 5 JR4 2 6 1 0 A 7.0 Q^