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76A64 2D 0-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Supt of Building 5947 •:NO.
V e •L^I ("Iapyy �TFOR APPLICANT TO FILL IN T
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL V'e er
BLOCK TRACT ADDRESS
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NO. OF SLOGS. 5926 • T. -- •
SIZE OF LOT NOW ON LOT CITY Ttj
USE OF DISTRICT NO. GROUP PROCESSED BYBUILDINGS Residence P
CONTRACTOTr
ADDRESS • e'er CONNECTION DATA
c • STATION /� DEPTH
CITY .J3,a TEL. NO. - -
ATE
REGISTRATIZC12.525 El COUNTY MANHOLE REFERENCE T' ( UPPER
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB L.
M.L.TO P.L. Y
PUBLIC SEWER @ $5.00 _
SEPTIC TANK,SEEPAGE PIT OR JOB NO. /L O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
V
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 Ix
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR. IN DATE O
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD U
UJI
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 CL
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 Oo
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
'I 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_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT '
New CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS_ 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 COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED ASOR ED LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T AN THE LEGAL OW NE OF, AND,(NTEND TO DISCONNECT PLUG AND
RESIDE IN, THE E DESCRIBED REBID AL POPdRTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE lll......
SEEP,PIT(S) ElCESSPOOLS ❑
VALIDAT199 ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH
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