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24650 INS TS
CE8O8 A-°QAPPLICATION FOR PERM - -
>sneazo COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER - - SEWER-SE AGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDINGOILASTBIy
ADDRESS
]LL A. . JENSE. County p't Engineer
'
AMAJENSEN. Supt of Building LOCALITY '
-- NEAREST
FOR APPLICANT TO FILL. IN CROSS ST.
LEGAL '
DESCRIPTION LOT NO A n' OWNER - -
BLOCK TRACT �/ iADDR - -
ADD
NO.OF BLOBS.
SIZE OF LOT NOW ON LOT / CITY TEL. NO.
USE P�MANHOLE
ICT GRI MAP I PROCESS41)BY
BUILoll,NGS
BK PG 7�
CONTRACTOR 13-2-1
� G
ADDRESS CONNECTION DATA
CIT TEL.N0. _ / TION -DEPTH
TATE REFERENCE ))���REGISTRATION NO. COUNTY W, OWER
No. DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO QO y (iJP
PUBLIC SEWER C� $3.00 o TYPE OF CONNECTION LENGTH FROM ^/
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD 02
EXTN..CESSPOO L. DRYWELL @ 52.00
P,C.N0.
HOUSE SEWER CONNECTING TO CO, IMP. N0. JOB NO.
PRIVATE DISPOSAL SYSTEM @51.00 '
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. V
WORK TO HOUSE SEWER @ EI.00 '
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0. O
INDUSTRIAL
WASTE APPROVAL w '
CHARGES 9
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE _
AUTHORIZATION TOTAL FEE V REIMBURSEMENT FEE
I NAVE AT THISCONNECT A CONTRACT WITH THE HEREIN NAMED CON-_ - APPROVALS DATE INSPELrTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC SEWER. "�� A
SIGNED THIS - - DAY OF - 19— NEW HOUSE SEWER <-vglf isA
OWNER OR1•� Y7/� CONNECT ADDITIONAL r
OWNERS AGENT C� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY.ACKNOWLEDGE THAT-I.-HAVE ,READ THIS.APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY j CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING_ ALT ER,REPAIR_SEWER OR
PLUMBING AND SEWERS. -' SEWAGE DISPOSAL SYSTEM '
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES.COUNTY AND STATE OFpBAN00 ABANDON-HOUSE SEWER -
CALIFORNIA OR THAT 1 M THE GAL OWNER 0 THE ABOVE
DESCRIBED RESIDENTI OPERT BACKFILL SEPTIC TANKS ❑
SIGNATURE' SE P.PIT(S) [3 CESSPOOLS
OF PERMITTE
®r VALIDATI I� ROBERT A. WOOD
CK. (❑❑(, U.0. . CASH SL fPERVISING MECHANICAL ENGINEER
- .. _ I.JLL'D2 5 7 4b SE�� 1 , .l. '-} . . 5.,0 V
24650!INSERTS,;
7Ea°a a.a°
>agsazo APPLICATION! FOR PERMIT ( .
- ''
COUNTY OF LOS ANGELES SEWER-SEW GE. D.ISPOSAL, ..
DEPARTMENT OF COUNTY ENGINEER - ---—
BUILDING AND SAFETY DMSION BuuolrvG
ADDRESS
ILL A. LAMBIE. CSVY Enggineer
WILL A. 1 SEN. SuP I of Building 'LOCALITY
NEAREST i
0.4 jpk A O F _ 'caOSS ST. '
L __
EGA ...
DESCRIP ON LOT NO.J OWNER
BLOCK TRACT' - MAIL -
ADDRESS
0.0 BLDGS.
SIZE OF LOT NOW LOT PITT TEL. NO.
USE DI DISTRICT NO. GROUP MAP PISP OCESSE Y
BUILDINGS
CONTRACTOR I ('�� �I K 3�I
ADDRESS, �I ll�,�J/IICONNECTION DATA
CIT
TUL. _ S/ ATION DEPTH
REGISTRATION N0. X52/ll / IrCOUNTY ST ANHOIE REFERENCE
LOWER
No: DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ S3.00dNAMEDCON�
TYPE OF CONNECTION LENGTH FROM i
SEPTIC TANK.SEEPAGE PIT OR .Y. CURB P.L.- M.L.TO P.L.
PITS ANO/OR GRAINFIELD @ E3.00
1 OVERFLOW SEEPAGE PIT. DRAINFIELD �� 9�Ute_ -
EKTN.,CESSPOOL. DRYWELL @ S2.00 77 /
HOUSE SEWER CONNECTING TDSCO. IMP. NO. 6(, FJ JOB NO, I
PRIVATE DISPOSAL SYSTEM @ 51.00
CONNECT ADDITIONAL BLDG.ORTRUNK PERMIT NO. ROAD PERMIT NO.. S O�SOL _ V
WORK C HOUSE SEWER @ SI.00
SEWEF OR DISPOSAL SYSTEM HOUSE @ $100STATE ENCROACHMENT
PERMIT N0. O
, INDUSTRIAL U
WASTE APPROVAL M
J _ - CHARGESO R'S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
INAVE AT Tx15 DATE A CONTRACT WITH TME HERETRACTOR TO CONNECT THE ABOVE DESCRIBED EXISAPPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS- -DA CNEW ONNECTS ADDITIONAL - - - - -
OWNER OR /jUp CONNECT ADDITIONAL
. OWNERS AGENT -BUILDING-0RWORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
.AND/OR DRAINFIELD.
1-HEREBY ACKNOWLEDGE THAT J HAVE READ .THIS APPLICATION_AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLT CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - ALTER.REPAIR,SEWER OR _
PLUMBING AND SEWERS. - - - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIREER
LOS AI GELES COUNTY AND STATE OF -ABANDON HOUSE SEWER- "
CALIFORNIA OR THATM TH LEGAL OWNE THE ABOVE
DESCRIBED RESIDENTIOPE BACKFILL SEPTIC TANKS ❑
SIGNATURE - 5 :PIT(S) [I CESSPOOLS OF PERMITTE
Wr VAIMATIO ROBERT A. WOOD
CIL M.0. CAsx SUPERVISING MECHANICAL ENGINEER _-
r�2 5 6 3 SEP ]_ =� 1 1 D
25.00