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76A642D APPLICATION OR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEW G DI O AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADORES
WILLIAM A. JENSEN, Sup't of Building C_
LOCALi
NEA ST
FOR APPLICA TO FILL IN CR 5
LEGAL
DESCRIPTION LOT NO OWNER
Y MAIL
BLOCK TRACT ADDRES
Ko6F B GS
SIZE OF LOT NOW ON LOT CITY JEL NO
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
B` PG
CONT C lo
5-4 Ti Iry
ADDRESS 1
1 CONNECTION AT
S ON ..y..O O DEPTH
CITY TEL. 1
ST TE MANHOLE REFERENCE �,e� S O U O, UPPER
REGISTRATION NO � ❑ COUNTY IIJJ
_ DESCRIPTION OF RK FEE TYPE OF CONNECT LENGTH FROM �--�
HOUSE SEWER CONNECTING TO ,^,l Y. CURB M.L TOP L
PUBLIC SEWER @ $5.00 (�f V
SEPTIC TANK,SEEPAGE PIT OR P.0 NO. �• O
PITS AND/OR DRAINFIELD @ S1000 CO IMP. NO. JOB NO /✓•
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 C
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MAN HOLE @ $5 00 W
OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE HWY. h
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 Oo CHARGES
AUTHORIZATION TOTAL FEE D CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE H EIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED XISTING DWELLING
'S SIG NATO RE
TO THE PUBLIC•SEWER APPROVALS DATE INSPECTOR
SIGNED THIS OF 19_
OWNER OR NEW HOUSE SEWER G��'G' 't`•L � "� �f'
OWNERS AGENT CONNECT ADDITIONAL y Y
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 ❑
1HEREBY CERTIFY T I AM PROPERLY (STERE AN YOR ALTER, REPAIR,SEWER OR
LICENSED AS REO Y LOS ANGLES TY A STA OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T 1 AM THE LEGAL O ER F. D IN ND TO DISCONNECT PLUG AND
RESIDE IN, TH BO DESCRIBED RE NTI O ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT T 5E CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M O CASH
L;�Uo 6 4 8 9.0; DEC 4 1 0 D 7.0 0— �'