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76A64 10_62 APPLICATION FOR PERMIT
78A 842D f
COUNTY OF LOS ANGELES SEWER-SEWAGF, DISPOSAL
EPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS .
WILLIAM A. JENSEN, Sup't of Building 6
LOCALITY
NEAREST
OR APPLICANT TO FILL IN CROSS ST. �j
LEGAL ,( - s -e.i '+" /�'�
DESCRIPTION LOT NO. T� 6 OWNER Y�
� MAIL
BLOCK TRACT �..�•�'G'��tyvc� ..�Ll.�r� [, ��. ( ADDRESS
NO. OF BLDGS. �)
SIZE OF LOT NOW ON LOT CITY TEL. N (f/
USELDINGS qTION
T NO. GROUP MAP PROCES D BY
CONTRACTORCONNECTIOd) DEPTHCITY TEL. NO. _ 6' 91'ATE MANHOLE REFERENCE PPER
[4-�
REGISTRATION NO. - ❑ COUNTY 1
NO. DESCRIPTI N OF WORK FEE TYP OF NNECTI N LENGT FROM J O
HOUSE SEWER CONNECTING TOP.L. M.L.T P.L. (�
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO"-� ///.yyy/� O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N '7-/
PRIVATE DISPOSAL SYSTEM @ $3.00 / / �IISSEddd
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 H
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 /9 +
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING�!/
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHME T�
PERMIT NO.
IND STRIAL
WA EAPPR VAL
d IV OWNERS PERMIT i 00 c A E
HARGE FEE
AUTHORIZATION TOTAL FEE CONNECTION C
IHAVE AT THIS DATE A CONTRACT WI THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DE CRIBED EXISi1NG DW ELLI G
TO THE PUBLIC SE, E ✓ APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGE T 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 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
[:LICENSED AS REQUIRE BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM TH LEGAL OWNER OFOND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DESC EDRESIDEN L PER ABANDON HOUSE SEWER
IGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS 01 1
dov
ALIDATIOI�1 ROBERT WOOD
\/ SUPERVISING MECHANICAL ENGINEER
M.O. CASH
ivy >.� i 61C) D �.1J`
0-8
76A642D A®PL Os PTOON FOR
PERMIT yl
COUNTY OF LOS ANGELES SEWER-SEyVAGE D ,SPOSAL
DEPARTMENT OF COUNTY ENGINEER )
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY ,�'.s;v� ^_�j�-��-,_�•
NEAREST
R APPLICANT TO FILL IN
CROSS ST.,
LEGAL L•
DESCRIPTION LOT NO. "— �"_ OWNER
C MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS -....D: .-__:
(STRICIC T N GROUP K MAP PROCES D'BY
B PG
a F
CO NT RACTO���
.'
ADDRESS er ���� tell CONNECTION DATA
CITY �,Z? EL. N , v,yf� T TION DEPTH
PPE
STATE MANHOLE REFERENC
REGISTRATION NO. �® Ye ❑ COUNTY E
NO. DESCRIPTION OF WORK FEE TYPE OF CONNE TION M.ENGTH FRO4( O
OUSE SEWER CONNECTING TO Y. CURB P.L. L.TO P LM. � V
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. •10B NO. O
_ HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMITNOY '//y G
PRIVATE DISPOSAL SYSTEM @ $3.00 / W
CONNECT ADDITIONAL BLDG.OR r AFFIDAVIT WAIVER EASEMENT RECORD, INSTR,NO, DATE H
WORK TO HOUSE SEWER @ $3.00 y
OVERFLOW SEEPAGE PIT,DRAINFIELD b
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 �{
REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWE ORD B EM @ $3.00 STATE ENCROACHM
/e�Z ` L✓L'� PERMIT NO. 1�
IND STRIAE
W EAPPROVAL
OWNERS PERMIT $ FfATRGES
AUTHORIZATION TOTAL FEE ®, CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
" TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. A 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)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS 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 ❑
t HEREBY CERTIFY THA /�I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT THE ' AL OWNER OF, AN INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AS DESCRI Fi0 R ME TIAL F'R RTY. ABANDON HOUSE SEWER
SIGNATURE H� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION--, ROBERT A. WOOD
( SUPERVISING MECHANICAL ENGINEER
CK. M.0. CgSH
2 6 1 ..