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CEfI°a''°.63 APPLICATION OR PERMIT
16Af4�D
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
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FOR APPLICANT TO FILL IN CROSS BT
LEGAL
DESCRIPTION LOT NO OWNER
_ MAIL !�
BLOCK TRACT O ADDRES
NO OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
� T BK PG
CONTRACTOR ) V• • �-(Qf r-��YJ
ADDRESS CONNECTION DATA
CITYEL A TATION 1� DEPTH
❑ ATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY L3
NO. CESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FRdM r7
HOUSE SEWER CONNECTING TO '1 Y CURB P L ML TO P L GSC }
PUBLIC SEWER @ $5.00 (}"[J
SEPTIC TANK,SEEPAGE PIT OR P.0 NO O O
PITS AN OR O
OR DRAINFIELD @ $10 00 CO IMP. NO. JB NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $300 /ix O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT-DRAINFIELD V L)
LU
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM IN $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE / " CONNECTION CHARGE FEE
-1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E) NG DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS _19-
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTER D AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQ D BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O AT I AM THE LEGA ER O A INTEND TO DISCONNECT PLUG AND
RESIDE IN. E ABO E DESCRIBED #4E SkEfE N T I PR PERTY ABANDON HOUSE SEWER
SIR
OF PER CKFILL SEPTIC TANKS ❑
OF PER
SEEP.PIT(S) ❑ CESSPOOLS []
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M.O CASH
2 1 3 9% AUG 3 1 0 0 7.0 0N