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76A6420 APPLICATION FOR PERMIT �I
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING b'��r/ Qy��h���T
JOHN A. LAMBIE, County Engineer ADDRESS T
WILLIAM A. JENSEN, Sup't of Building I
LOCALITY
NEAREST
FOR APPLICANT TO FII L IN `"OSB 3T.
LEGAL
[ADDRES;!
CRIPTION LOT NO, , OWNER Gf/
/� MAIL
CK TRACT 9�p` ADp RE 5 �J
(P(/�\ (J� NO. OON LOTS CIT NO.
OF LOT `
OF TR ICT
NO. GROUP MAP Pfl ESSED By
LOINGB
_ BK PG
TRACTO
CONNECTION DATA
TEL. NO. STATION J 3I G DEPTH
STATE MANHOLE REFERENCE i/�S cJ1 UP
REGISTRATION NO. COUNTY OWE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION•J, L&NGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $3.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR O }
PITS PND/OR GRAINFIELD sono CO. IMP. NO. JOB NO. 0
HOUSE SEWER CONNECTING TO THUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADD ITIONAL BLDG.OR AFFIDAVIT I RIJVII I IIIIKINT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD V
EXTN..CESSPOOL.DRYWELL.MANHOLEG $3.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING W
OL
SEWER OR DISPOSAL SYSTEM $3.00STATE In
PERMITENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE OE3 BED EXISTING WELLING
TO THE PUBLIC SE ER. _ APPROVALS DATE IN SP !2S SIGNATURE
SIGNED T HIS DAY OF
OWNERORNEW HOUSESEWER
OWNERS AGE T—
CONNECT A111111"AL
ADpRESY
/J BV ILDING OR WORK
SLFIIIC TANK,SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORpINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOU'RED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO r5Cji1BED DENTI PROP RlY ABANDON HOUSE SEWER ❑
SIGNATURE ,q{f'n..ai
OF PERMITTEE BACKFI LL SEPTICTANKS
SEEP,PIT(5) ❑ CESSPOOLS ❑
/ yALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.0. CASH
LAC0 6 3 6 1 OCT 13 1 0 A 7I0 0, a