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76A6420 APPLICATION f'( PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDoING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building o VOID Ve •
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL Veber De VTT
o
BLOCK TRACT2990a ADDRESS T
NO. OF SLOGS. e T. • `T •
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF Residence DISTRICT NO. GROUP MAP PRO.C�ESSED BY
BUILDINGS /� A :
CONTRACTOR
ADDRESS B . `' CONNECTION DATA3245
NaAve .
CITY S TE STATION Q• DEPTH J
t 5brl SP
REGISTRATION N0202 52 5 e COUNTY%Y MANHOLE REFERENCE d,O � UPPER
^, NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB .L. M.L.TO P.L.
PUBLIC SEWER $5.00
SEPTIC TANK,SEEPAGE PIT OR P.G.NO. F r� O
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP. NO. JOB NO. /
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ 53.00 - 1w
CONNECT ADDITIONAL BLDG.OR =VER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5,00
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING hy
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT L
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ) .
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
Y TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPEC OR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
New
ADDITIONAL
ADDRESS New BUILDING OR WORK
I 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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUI B LOS ANGLENTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH 1 A THE LEGAL OWN OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE V DESCRIBED REST TIAL O RTY. ABANDON HOUSE SEWER
SIGNATURE /
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
/
SEEP.PIT(S) 11CESSPOOLS ❑
VALIDATIOI1 ROBERT A. WOOD
GK. M.O. SUPERVISING MECHANICAL ENGINEER
7.0 0 CASH L
r �6 1 0 A0 U ��15:3 A Q