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S&E-689 11.55 APPLICATION FOR PERMIT 1
S&E•6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING �� `���
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 7�!
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY7/r ,a-,,eNEAREST
�fy
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL / OWNER
DESCRIPTION LOT N0. '�JO t
6s G / MAIL
BLOCK TRACT ADDRESS
-7 C NO. OF BLDGS.
SIZE OF LOT ( /J NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP
BUILDINGS � BK PG
CONTRACTje
OR
ADDRESS �� {� /) DEPT
CONNECTION DATA
' � 3
CITY `O �• TEL. N0. (p.2/� MANHOLE REFERENCE
TATE / /I s LOWER
S
REGISTRATION NO. �f��i0'Sf'7 ❑ COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH FROM
PUBLIC SEWER Lla $3.50
Y. CURB P. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR axPITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD `� P. C. N0.
P
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 CO. IMP.NO. d JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ER'GROACHMENT 1
WORK TO HOUSE SEWER Q $1.00 PERMIT NO. _��'�• _
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM C $1.00 WASTE APPROVAL /
....CHARGES
CONNECT CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE rk�>
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSP CTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIB D EXISTING DWELLING
TO THE PUBLIC SEWE NEW HOUSE SEWER
SIGNED THISF ^ 19%51 7 CONNECT ADDITIONAL a
OWNER OR BUILDING OR WORK
OWNERS AGEN SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT AVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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 COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIATHAT AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEORN AL ROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S) [ICESSPO
SIGNATURE OLS El
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIO ROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK. M.0.LAC05'*' FEB 4 4.5C
0-63,
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Z
JOHN A, LAMBIE, County Engineer ADDRESS��
WILLIAM A. JENSEN, Sup't of Building - r _
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. %,16) -
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS _
NO. OFIBLDGS.
SIZE OF LOT NOW ON LOT Cr,A_ CITY TEL. NO.
BUIELDIN OF GS a \\\N� DISTRICT NO. GROUP BK MAP PG PROCESSED BY
544
CONTRACTOR ��4 L
ADDRESS `j tco %3f- CONNECTION DATA 9
CIT TEL. NO. 0 O STATION19 _ DEPTH
r� STATE MANHOLE REFERENCE
REGISTRATION NO. ` Zo COUNTY �-3 LOW
NO. 1 DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM.` /Y
HSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. N�K }
PUBOULIC SEWER @ $5.00d
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. , JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 w
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00 ~
V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY.OR ST.WIDENING N
BANDON HOUSE �.
SEWER OR.WSP SAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER"S PERMIT s 2 Oo
AUTHORIZATION TOTAL FEE tyI CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [:1DRYWELL C1
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED 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 DESCRIBED RESIDENTIAL PR PERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE �-G ���333 -- SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CM.O. CASH
W.
7429- NOV1810 D 5.00-