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76A642D - APPLICATION FOR PERMIT
6A642 '"
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FO A I T TO LIN CR055 5T.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT r/ ADDRESS
J f� NO. OF BLDGS.
SIZE OF LOT `./C,' NOW ON LOT CITY TEL. NO.
USE OF
USE OF
DISTRICT NO. GROUP MAP PRI3 SED BY
BK PG J\
CONTRACTOR e'
ADDRESS CONNECTION✓DATA
CITY TEL. NO.
TATE
STATION DEPTH
UPPER
MANHOLE REFERENCE LOWER
REGISTRAT S
NO. COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. .L.TO P.L. }
PUBLIC SEWER @ $5.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP.NO JOB NO. V
HOUSE SEWER CONNECTING TO U IIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMEN RE OR .197fR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL,MAN HOLE @ $5.00
ALTER, N HOUSE '�
HWY.OR ST.WIDENING
SEWER OR-Df9rC6AL SYSTEM 53.00 STATE ENCROACHMENT --
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
AUTHORIZATION I TOTAL FEE 4:$_6
CONNECT IO HARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REI.. RSEMENT 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_ CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
—.
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH15 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 SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGED ISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THEABO ]BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH