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76A642D APPLICATION 9.�APP ICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS N ,A A
WILLIAM A. JENSEN, Sup't of Building LOCALITY San Gabriel
NEAREST Leslie o
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. 5 OWNER
MAIL
BLOCK TRACT 29908 ADDRESS 5926 N T C B1 yd
NO. OF SLOGS. 1T O O TEL. NO.
SIZE OF LOT NOW ON LOT CITY
Ld
USE OF e e DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS 0
CONTRACTOR HenryB
ADDRESS 32457N. Ivan Ave o CONNECTION DATA
: CITY SSGO TEL. NO. At O 0-4772 STATION.:�I# DEPTH
❑ STATE MANHOLE REFERENCE -iiPPL
REGISTRATION ElCOUNTY " C ,% LOWER
NO. GES F WORK FEE TYPE OF CONNECTION LENGTH FROM or
HOUSE SEWER CONNECTING TO Y. CURB .L.. M.L.TO P.L.
PUBLIC SEWER @ S5.00 p�
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO, O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 ix
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER - @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
a WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 00
AUTHORIZATIONI TOTAL FEE Y ' 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
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS _ DAY OF 19_ l '
OWNER OR NEW HOUSE SEWER
OWNERS AGENT New CONNECT ADDITIONAL /" r
BUILDING OR WORK
ADDRESS
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 SEWE S. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERT AT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS R I ED LOS ANGLES CO TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O AT I THE LEGAL OWN OF, AND Irj END TO DISCONNECT PLUG AND
RESIDE IN, ABOV DESCRIBED REST TIAL PR E �Y. ABANDON HOUSE SEWER
i
SIGNATURE ' BACKFILL SEPTIC TANKS ElIT
OF PERM ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH R 7 0