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CE808 e•59 APPLICATION FOR PERMIT
E808
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION AID RESSG t!
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
CROSS ST. Z
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS .�
NO.OF BLDGS. {'
SIZE OF LOT Q L� NOW ON LOT CITY TEL. N � 41 t9
USE OF
BUILDINGS Jop DISTRICTA. GROUP BK PO'MAP PROCESSED BY
A I � /Z
CONTRACTOR
ADDRESS ^ �` /Q t CONNECTION DATA
CITY TEL.Np �� STATION DEPTH
TATE MANHOLE REFS NCE UPPER
REG T ATION NO. COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE
ER
SEWSPUBLIC 5 27 It
CONNECTING TO @ $3.00 �� a
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. RB P. M.L.10P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PER MITNO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00 •
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVA
CHARGES
OWNERS PERMT t 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE e-e REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 CT PLUG AND
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CTPLUGHOUSE D
CALIFORNIA OR THAT AM THE LEGAL OWNER OF THE ABOV
DESCRIBED RESIDENT! PRO RTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.
PIT
(S) ❑ CESSPOOLS
111 OF PERMITTEE
®r MY-
VALIDATION--, ROBERT WOOD
6 Y
C .o. CA98 SUPERVISING MECHANICAL ENGINEER
6 . l n 3 .0
E-6D
S& 63 11.55
APPLICATION FOR PERMIT 1
S •6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles ADDRESS BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT of BUILDINGLOCALITY 7-_��j G
FOR APPLICANT TO FILL IN Ross STc1
LEGAL C�
DESCRIPTION LOT NO. / OWNER eCle
BLOCK TR`1CT ` 3 '7 MAIL
/ ADDRESS _S rYl
/ N0.OF BLDGS.
SIZE OF LOT �' NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. G2 MAP
BUILDINGS "�-� IQ BK PG�.i
CONTRACTOR C
L _
ADDRESS ; 5� / ���)y 1 'QCONNECTION DATA
CITY f s TEL.NO.17 7, 77 2- STATION v�� ' DEPTH
04 MANHOLE REFERENCE
CE UPPER
G / C3STATE
�-7
REGISTRATION NO. g Z / /,(C ❑ COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
Y TYPE OF URB TION
P.L. LELGTO TH FROM �c�
P. P-PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD JO
CO. IMP. NO, B N O
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.(�
CONNECT ADDITIONAL BLDG.OR ` J STATE ENCROACHMENT
i
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. J - NEW HOUSE SEWER '67 S O
SIGNED THIS D OF v_' 19�L CONNECT ADDITIONAL
OWNER OR I / _BUILDING OR WORK
OWNERS AGENT ` SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE 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 S ATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE L�iGAL OWNER OF TH ABOVE
DESCRIBED RE ENTI L PROPERTY./L'/ // BACKFILL SEPTIC TANKS❑
SIGNATURE �_;I / _S_EEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE 1 v
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATIO ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N.O. GASH
fi,
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