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E.6. - APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer - - -'
County of Los Angeles BUILDING ., ..
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS _
® CASSATT 0. GRIFFIN, SUPT OF 9u LLolrvc - LOCALITY
FOR APPLICANT TO FILL IN, caoss sr.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
SIZE OF LOT
NO. OF BLDGS, CITY
NOW ON LOT TEL. NO.
US
BUILDDINGS
E �--�w DISTRICT~NO. GROUP MAP
BK PG
CONTRALTO
�_ � �� _ CONNECTION DATA
ADDRESS
STATION J (J A
^— DEPTH
CITY = TEL. N0. MANHOLE RE ERENCE C� PPER
STATE
REGISTRATION NO,' H] '
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ S 3.50 �� P.L'. M.L. TO P.L.
OF
SEPTIC TANK,SEEPAGE-PIT OR
PITS AND/OR DRAINFIELD Q $3.00 A P. C. NO.
OVERFLOW SEEPAGE PIT. DRAINFIELD CO. IMP.N0
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $ 2.00 —� ma, /
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q S 1.00 c TRUNK PERMIT NO. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR - STAT CROACHMENT
WORK TO HOUSE SEWER Q $L00 PERMIT!
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM (U? S 1.00 - WASTE APPROVAL -
CH EB
CONNECTION CHARGE_F
OWNER'S PERMIT s t 00
AUTHORIZATION ITOTAL FEE REIMBURSEME EE
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE AB VE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC SEWER. NEW HOUSE SEWER L ��
SIGNED THIS Y 19 CONNECT ADDITIONAL b p
OWNER. OR BUILDING OR WORK -
OWNERS AGENT _ SEPTIC TANK,SEEP.PIT(S) -
ADDRESS AND/OR DRAINFIELD
1
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLL
AND,STATE THAT.THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,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 COUP AND STATE OF ABANDON HO PLUGAUSE D `
CALIFORNIA OR THAT I AM THE EG L O ! B O THE ABOVE _
DESCRIBED RESIDEN ROPER BACKFILLSEPTICTANKS❑
SIGNATURE SEEP. PIT(S) ° CESSPOOLSLJ
OF PERMITTE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLEIG. INSPECTOR
Y/'•j Y.,O, CASH
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