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CE36OS 4 3
E 213 APPLICAT ON FOR PER IT
COUNTY OF LOS ANGELES SEWER—SEGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BGILOIN -
JOHN A. LAMBIE. Cou¢ty Engi¢ear ADDREs9 d
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NE4REST . A
FOR APPLICANT TO F LIN R.. "T 9T.
LEGAL O
DESCRIPTION LOT NO. O
MAIL WNER
BLOCK ADORES$
NO. OF SLOGS,
SIZE OF LOT NOW ON LOT CITY 1 r TEL..NO.
USE OF DISTRICT NO. GROUP MAP
x/ PROC SEO BY
BUILDINGS
fiBK PG
CONTRACT 1 D V H
ADDRESS 3 `/ S CONNECTION D TA
CITY TEL. STATION PA DEPTH
'] R TATE MANHOLE REFERENCE
SCJ
REGISTRATION NO. /w LJ COUNTY >� / LOWE
NO. DESCRIPTION OF WORK E TYPE OF C ION LENGTX FR
HOUSE 9EWER CONNECTING TO Y. CU P.L.
PUBLIC 6EW ER ® f3.00
SEPTIC TANK.9EEPAGE PIT OR
PITS ANO/OR DRAINFIELD f10.00 CO.IMP.NO. JOB NO. 1
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.ORAFFIDAVIT wMVNI IMuRRi RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ® $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD 1—
E%TN.,CESSPOOL,ORYWELL,MAN HOLE® $5.00 U
ALTEq,REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING W
SEWER OR DISPOSAL YBTE ® f3.00 u`
STATE ENCROACHMENT _ Z
�i^ PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS If PE z 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWE LINO
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ _
OWNER ORNEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(8)
1 HEREBY ACKNOWLEDGE ABO THAT HAVE READ THIS APPLICATION gryO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE E LATING
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTEEEI{{IED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY L09 ANGLES
COUNTY ANO S''TAAATgTEEOOF SEWAGE DISPOSAL SYSTEM
GLIFOR NIA OR T AT PM THE LEGNEfl OF, AN(a
RESIDE IN. THE DESCRIBED R ENTI . E I IBCONNECT PLUG AND
O jBANDON ROLSESEWER
SIGNATURE �+ BACKFILL SEPTIC TANKS ❑
OF PERMI SEEP.PITIBI ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK. M.0.
cnsH SUPERVISING MECHANICAL ENGINEER
,_, 6 3 0 a•^ CCT _l. 1 :l. D 3.0 0"