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COUNTY OF LOS ANGELES SEWE —SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESSy
WILLIAM A. JENSEN, Sup't of Building /r
LOCALITY G.►
NEAREST
FOR APPLICANT T FILL IN GROSS ST.
LEGAL ,
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDR S
NO. OF SL GS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
CONTRACTOR �L9 IF •3/—.ter+ BK PG ^`ir
ADDRESS CONNECTION DATA
CITY EL. NO. STATION ---0 -14- 7,9 DEPTH
❑ STATE MANHOLE REFERENCE K/ UPPER
- REGISTRATION NO. ❑ COUNTY �Q S '
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO �/; Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 l5 V vQ�
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. �J O
Y PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. /V
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00
V
OVERFLOW SEEPAGE PIT,DRAINFIELD 6J,J
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
I (yn
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT b
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 Oo CHARGES
AUTHORIZATION TOTAL FEE 1
-7 &-0 CONNECTION CHARGE FEE
A RAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED-CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ �, (( f /,_. 4r! c
t
OWNER OR ���/J NEW HOUSE SEWER �Ir�(J �i ✓ , =.M�
OWNERS AGENT /� CONNECT ADDITIONAL v '
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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED A DOR ALTER, REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND T OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT THE LEGAL OWN AND TEND TO DISCONNECT PLUG AND
RESIDE IN, THE A E ESCft I.E. RESIDE L PR TY. ABANDON HOUSE SEWER
SIGNATURE ACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION� ROBERT A. WOOD
CK. M.O. CASH
CC SUPERVISING MECHANICAL ENGINEER
�;''. LACD 2 1 4 3.l AUS 3 1 0 D
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