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76A 6420 APPLICATION FOR PER 1T
COUNTY OF LOB ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
F:.
NGJOHN-A. LAMSIE. COUNTY ENGINEER " 2COLEMAN W. JENKINS. SuP•T. of BUILDINGrrY rSTFOS APPUC T FELL IN /T• al
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DE�CIIIPTIDN LOT NO. OVINER W T 1' �
/LOCK TRACT AI
DDRESS Q la t. M
No, OF ■LDOS.
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO. O OU INK = PROCESSED NY
■UILDINOS
Pa
139 CONTRACTOR R L/
ADDRESSN O Y CONNECTION TA
CITY 4 O TIL. NO. 4(.1-r D STATION DEPTH
STATE ` O CILASS yLICENSE NO,2— MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF Ion LIIIGTH FRo
HOUSE NEWER CONNECTING TO w Y. CURS P.L
PUSLIC SEWER 0 $5.00 (�
P.C.No.
SEPTIC TANK, AG[FIT Oft
PITS AND/OR DIIAINFIELD $10.00 CO.IMF.NO. .701 NO. /�
HOUSE SEWER CONNECTING TO TRUNK PERMIt NO. ROAD PERMIT NO. �{
PRIVATE DISPOSAL SYSTEM $3.00 L5
CONNECT ADDITIONAL RLDG.OR AFFIDAVIT I ■AIY" EAm"K[ RECORD.INSTR.NO. DAT[
WORK TO HOUSE SEWER 57.00
OVLIFLOW SEEPAGE PIT.DRAINF1ELD C'
POOLDRY
EXTN..CEDSW ELLMAOI f°
NHL .00
AL REPAIR O A NDOHOUSEHWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 41 7.00 STAT[ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
OWNER'S PEHMrf s 21 00 cHARGr/
AUTHORIZATION ?OTJLL FEE CONNECTION CHARGE FE[
I HAVE AT THIN DAT[ A CAC4
DN-
WITH T)IR HEREIN NAMED CM- R[IMSU RS[M[NT FE[
TRACTOR TO.CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE 1.USLIC SEWER. APPRO AU DAT[ IONATUR[
SIGNED THIS DAY OP 19_
OWNER ORNEW HOUSE SEE
WR
OWNERS AO[MT
CONNECT ADDITIONAL
BUILDIII0 OR WORK
ADDRESS
1 HERESY ACKNOWLEDGE HAVE READ I HAVREAD THI■ APPLICATION SEPTIC TANK.SEEP,PIT(/)
ACID/OR DRAINFI[LD
AND STAT[ THAT THE ASOV[ If CORRECT AND AOR[E TO COMPLY
WIT' ALL COUNTY ORDINANCES AND STATE LAWS R[OULATINO
PLUMBING AND •GIVERS. - CESSPOOL ❑ DRY* ❑
1HEREBY CERTIFY THAT I AM PRGPRRLY REOISTESID AHD/OR ALTER,REPAIR.SEWER OR
LICENSED AS R[OUIR[D by LO■ AHOLL COUNTY AND *TATE OF ■[WAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEO OW N[R OF• AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRI ED IDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑
OF P[RY BACKFILL°[ C TANKS ,Irl
oKKP.
P1718) Li CXS9POOL,
VALIDATION R. LLEM
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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