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C'808 APPLICATION FOR P'IERMIT .
EB088�88 COUNTY OF LOS ANGELES
SEWER-SEWAGE DIS OSAL
DEPARTMENT OF COUNTY ENGINEER - - -
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE. Cou.ty Engineer - -
CASSATT D. GRIFFIN, Supt of Building LOCALITY
..: NEARE
ST
STNT"
P.OR APPLICATO FILL IN cROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER B :ey IMAIL ' /)
BLOCK S ADDRESS 0/r? A 71� /14
NO. BLDGS. 'T—
SIZE OF LOT NOW ON LOT CITY TEL, NO Z.
USE OF
BUILDINGS DISTRICT•NO,. GROUP BK PG MAP ,E MCESSED By
l 1-3 f
CONTRACTOR l O IF— O /
^
ADDRESS O CONNECTION DATA
CITY TEL. NO. 2 STATION 0• DEPTH
STATE MANHOLE REFERENCE Z UPPER
REGISTRATION NO. ~ COUNTY
No. DESCRIPTIONF WO -RK FEE
HOUSE SEWER CONNECTING TO Q [
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB .L: M.L.TO P.L..
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO '1 C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. / 2 JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERM 0.
WORK TO HOUSE SEWER @ $1.00 t
SEWER OR DISPOSAL SYSTEM HOUSE @ $1.00 STATE EI
FM E!
PERMIT N0.
INDUSTRIAL
_ WASTE APPR L
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHOMATION FTOM FEE REIMBURSEMENT FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE. INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE
E .
SIGNED TH AY OF NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS I AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATI
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEW AGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL WNER OF TIJE ABOVE
DESCRIBEDIAL FROPETRI ` BACKFILL SEPTIC TANKS[I�. SIGNATURE SEEP. PITS) [ICESSPOOLS
OF PERMITTE O
JV LIDATION ROBERTA.WOOD
CK. H.o. CASH SUPERVISING MECHANICAL ENGINEER