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768663 62 APPLICATION OR PERMIT
�eseazo COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS l' f
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST ,L
LEGAL
DESCRIPTION LOT NO All2, OWNER �Cw
MAIL r
BLOCK TRACT ADDRES
NO OS
SIZE OF LOT NOW ON LOTCITY TEL NO
USE OF DISTRICT NO GROU MAP PROCESSED BY
BUILDINGS /'
l' J. Q�
CONTRACTOR /�t��wJ �d'y a>� Cr( V �0 91 Lei
ADDRESS y y/ CONNECTION DATA
CITY �� TEL NO a STATION DEPTH
LICENSE NO (�j_7,9� CLASS I ,..., ✓ MANHOLE REFERENCE
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LIENGTH FR M
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP d
PUBLIC SEWER §5 00
SEPTIC TANK SEEPAGE PIT OR 1 P C NO O
PITS AND/OR DRAINFIELD ® §1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ix
PRIVATE DISPOSAL SYSTEM $3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIYEN I EASEN[NT RECORD JNSTR NO DATE V
WORK TO HOUSE SEWER $300 lov
OVERFLOW SEEPAGE PIT DRAINFIELD Lu
CL
EXTN CESSPOOL DRYWELL MANHOLE @ $500 1)
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT A
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT S z 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
(�(
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONN REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER APPROVALS lrTF INSP TOR S SIGN TU RE
/j_ _ /
SIGNED THI DA^4 Y�Y _ 19- !P
OWNER O NEW HOUSE SEWER
OWNERS G CONNECT ADDITIONAL
ADDRESS /J BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE T T I HAVE READ HIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I 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
CALIFORNI OR THAT 1 AM E LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE HE ABOVE D RIBED RESIOCf1TIAL PROPERTY ABANDON HOUSE SEWER
SIG UR UU BACKFILL SEPTIC TANKS
❑
O P M /1H SEEP PIT(S) ❑ CESSPOOLS ❑
V IDATIO?T- 1 JACK R ALLEN
`(CASH
SUPERVISING MECHANICAL ENGINEER
CK M O
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