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AB6R2� 63 APPLICATI N FOR PERM
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS v /Y�
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `Ross
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT A D
NO OF BLDGS _
SIZE OF LOT NOW ON LOT CITY/ TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS r BK PG
CONTRACTOR
—4-17177
ADDRE
CONN ON DATA
L/
CITY STATION `--� � /'_ DEPTH /�..
` STATE MANHOLE REFERENCE //4_7
El
REGISTRATION NO COUNTY 'l J
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO ^ - Y CURB P L. M L TO P.L f a
PUBLIC SEWER @ $5.00 (T�
SEPTIC TANK,SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ SIO 00 CO,IMP. NO JOB NO. r 7 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO _
PRIVATE DISPOSAL SYSTEM @ $3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR NO DATE II.-
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD l!J
EXTN,CESSPOOL..R1WELL,MANHO1_E @ $5 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT � z o0
AUTHORIZATION I TOTAL FEE 7
CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBEXIS IG D
ED WELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SI ATURE
SIGNED THIS DAY O .19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
' 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 I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQW0fD PY LOS ANGLE COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT I THE LEGAL OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH ABOV DESCRIBED ENTIA OPE RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERIM P.PIT(S) ❑ CESSPOOLS ❑
VALIDATION//"\ ROBERT A. WOOD
cK M O. . H SUPERVISING MECHANICAL ENGINEER
JA 2 t3 3.', AUG 3 1 0 D 7.00