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CE808.8.58 APPLICATION OR P RMIT , 1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer I NEAREST
ADDRESS *J
CASSATT D. GRIFFIN. Sup't of Building LOCALITY Z
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FOR APPLICANT TO FILL IN
CROSS ST. ` dez'&
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
/ ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF ,�yy
BUILDINGS ./tC�J� ,C��� DISTRICT NO.1 GROUP I MAP I PROCESS_WBY
CONTRACTOR
ADDRESS 20/' S o CONNECTION DATA
CIT7�/a/Jrr�+ TEL.NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. /�/�/��j/�'` COUNTY LOWER
NO. DESCRIPTION OF WO K FEE 5 ,
HOUSE SEWER CONNECTING TO /17
PUBLIC SEWER @ $3.00 —
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION/ LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 Co.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
/ TER'REPAIR OR ABANDON HOUSE ✓- STATE ENCROACHMENT
OR DISPOSAL SYSTEM @ $1.00 (•� PERMIT NO.
a ' tr VNDUSTRIAL STE APPROVAL
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE }� C' a REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON_ APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS SAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
L
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
MBING AND SEWERS. SEWAGE DISPOSAL SYSTEMHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORDISCONNECT PLUG AND
NSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
FORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVERIBED RESIDENT L P ERTY. ) BACKFILL SEPTIC TANKS ❑ATURE � SEEP. PIT(S) ❑ CESSPOOLS❑PERMITTE
®� ALIDATION ROBERT A.WOOD
U.p„ emu SUPERVISING MECHANICAL ENGINEER
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