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CEBOBXe Be •- . APPLICATION F,OR P li IT gas2 ,
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION - euamrvc
IOHN A. MB
LAIE, County Engineer ADDRESS
CASSATT D. GRIFFIN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO Fal IN _ Caoss IT.
LEGAL
DESCRIPTION LOT N0. OWNER t.
BLOCK TRACT MAIL
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW LOT CITY TEL. NO.
USE OF
CONTRACTOR DISTRICTjO. GROUP P
MAP PROCESSED BY
� u
ADDRESS CONNECTION DATA
CITY �— TEL.NO.l, Q J50,,&, I.PC I EPTH Z
STATE
REGISTRATION NO. '� B COUNTY L REF ENCE � U
LOWER
rvo. DESCRIPTION OF WORK EEI ✓Y ;ST ( fll
HOUSE SEWER CONNECTING TO Z
PUBLIC SEWER @ §3.00 TYPE OF CONNECTION LENGTH FROMY�
SEPTIC Tq NK.SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. J
PITS AND/OR GRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT
WORK TO HOUSE SEWER @ 51.00
A LTE R,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
EW Eq OP DISPOSAL SYSTEM c $I.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 5 2 OD CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGAPPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
' OWNERS AGENT BUILDING OR WORK
ADORES$ SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL EI DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR.SEWER OR
SEWAGE DISPOSAL SYSTEM
LY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
A OR THAT I M THE LEGAL OWNER OF THE ABOVE RESIDENT L OPERTY. BACKFI LL SEPTIC TANKS SEEP.PIT(S) ❑ CESSPOOLS ❑TTE
®' VALIDATION ROBERT WOOD
CK. M.o. usx SUPERVISING MECHANICAL ENGINEER
a
LA.Co 1 5 9 9 al 1 0 D 55.0 0
CEBOe2
5.59 _ • _• • LI AT ON FOR PERMIT�
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu1LOING E
ADDRESS
JDRR A. GRIFFIN,
Co=t, Sup I Engineer
CASSATL D. GRTFPIN, Sup t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROss sr. .VG/pVIT
LEGAL
DESCRIPTION LOT N0. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS,
SIZE OF LOT ! n - NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS .P 6Q---2 --L�- %- DISTRICT 10, GROUP MAP PROCESSED BY
PG
CONTRACTOR 5 06 I ' /K
T�
1 -33
ADDRESS j s r CONNECTION DATA
I
CITY A _ TEL.NO. p1/AG.((tp` STATION DEPTH I[�
STATE "
NO E REFERENC
REGISTRATION NO. COUNTY LO ERP
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO , Wra.sT "'M
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM r
SEPTIC TANK,SEEPAGE PIT OR - Y. CURB P.L. M.L.TO P.L. J
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.. CESSPOOL. ORYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ SI.00 CO.IMF'. NO./ L^ JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO.5?5 �.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT ,$ B— CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEEIL REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- '
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ 1 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE REPAIR,
SEWER OR
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE
DISCONNECTDISPOSAL PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA P OPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP. PIT(5) ❑ CESSPOOLS ❑
13 OF PERMITT •/� - /�},..y.i���
®r VALIDATION ROBERT WOOD
CK. Y.o. GSH SUPERVISING MECHANICAL ENGINEER
LALD 1 5 9 8 ' JUN 1 1 1 D 2 5 ,Q Q n