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10,6376A642D APPLICATION FOR PERMIT
6A64lJ
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
• JOHN A. LAMBIE, County Engineer ADDRESS J
WILLIAM A. JENSEN, Supt of Building
LOCALITY / �/4-1
NEARECROSS ST.
FOR APPLICANT TO FILL IN
LEGAL
[BLOCK
SCRIPTION LOT NO. C OWNER
.�J MAIL 1113-/3
TRACT J1 ADDRESS ✓ /v-
NO. OF SLOGS.
ZE OF LOT NOW ON LOT CITY e' / EL. NO.
EOF ISTRICT NO. GROUP MAP PROCESSED BY
ILDINGS
y� BK PG
CONTRACTOR �� K'�/ ' ®LI/J I jL
ADDRESS /�U c �' t, CO NEC' DATA
CITY / c' TEL. NO. �(q -_?sq-.? STATION DEPTH
q19 STATE UPPER
REGISTRATION NO.OG :! (A E] COUNTY MANHOLERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNEC LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P. M.L.TO P.L.
PUBLIC SEWER @ $5.00 N0.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB O
PITS AND/OR DRAINFIELD @ S10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 53.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1 ER EASEMENT RECORD. INSTR.NO. DA
WORK TO HOUSE SEWER @ $3.00 u
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXT N.,C ESSPOOL,DRYWELL,MANHOLE @ $5.00 HO / I
1,LTER,R HOUSE / z
SEWER M @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHA
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE /F�/) CONNECTION CHAR
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REI SEMENT 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
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 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 1 a�
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM V'.� .�{„'-.✓flf1�( l e ,
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND ° y
RESIDE IN, THE ABOVE DESCRIBED RE IDENTIAL PROPERTY. ABANDON HOUSE SEWER ✓
SIGNATURE 7//i BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,1IT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
44 � � ,� x, 101 D p 5.00