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7BA64XD APPLICATION FOR PERMIT
• I COUNTY .OF LOS ANGELES SEWER-SEWAG5 DISPOSAL
DEPARTMENT OP COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5 D
JOHN A. LAMBIE, COUNTY ENGINEER ADDRL"
COLEMAN W. JENKINS. SUPT. of BUILDING
LOCAL
NKAREST
FOR APPLICANT TO FILL IN - 1 `ROS `T
D[fLEGAL ON LOT NO. p
MAIL
(LOCK TFLA CT ADDRESS (��s
O. 00 .
■IZI OF LOT r JO / HOW ON■LOOLOTSC L. NO.
USF OF - - DIf"ICT NCJ QROUP MAP PROCESSED BY
BUILDINGS
■K PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO. STATION 1431 -0
/ -d DEPTH
STAT[ LIC MANHOLE REFERENCE/M /k//_0 UPP"
LICENSE NO, `S'A'M IJV
No. .DESCRIPTION OF WORK FE[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNETI
CNG TO ' CURB - P.L M-L-TO P.L. d d
PUBLIC SEWER $0.00 F.C.NO. O
CO.IMP - JOB HO.
SEPTIC TANK,SEEPAGE PIT OR `
PITT AND/OR DMINFI[L,!) � $
10.00
.NO. / (J
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 57.00 T_ O
CON N[CT ADDITIONAL AFFIDAVIT' •�[■ W[u RECORD.INRTR.NO. DATE r
WORK.TO HOUSE SEWER $7.00
OVERFLOW SEEPAGE PIT.DRAINFIELD p�
[XTN..C[SBPOOLDRYWELLMANHOLE $5.0-0 (n
AL R,R A R O AaA ON oUS HWY.OR ST.WIDENING / Z
SEWER ORD,
SYSTEM 3.0hj�O STAT[INCROACKM
P[RMiT NO.
INDURTR AL
WAST[APPROVAL
CHARGES OWNER
7�
' PtM= $ 2 00 .
A OIp��A ON TOTAL MM CONNECTION.CHARa[F[E
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON- R[IMBURS[M[NT F[I
TRACTOR TO CONNECT THE ABOVE DIfCR [DDWELLINQ
TO THE PUBLIC S APPROVAM DATE INSPECTOR'S SIGNATURE
SINNED THIS- DAY OF 1G
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
A DD RES■
BUILDING OR WQRK
SEPT ICTANK, FIT(f)
I H[R[BY ACKNOWL[D06 THAT I HAVE ROAD HIS APPLICATION AHD/OR DRAINFIRFI[LD
AND STATE THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND IFTAT[ LAWS REGULATING C[Sf POOL ❑ DRYW[LL ElPLU MBI NO AND SEWERS.
I HEREBY CERTIFY THAT I AM PROP[ REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LIC[NS[D AS REOUIR[D BY LOS ANGL 0UNTY D STATE OF ■[WAG[DISPOSAL SYSTEM
CALIFORNIA OR THAT I M TH6 L[ AL [R OF, D INTEND TO DISCONNECT PLUG AND
R[lID[ IN. TH[ A■ D[SCRI R[l NTI ABANDON HOUSE S[W[R
SIGNATUR BACKFILL SFT1G TANKS ❑
OF P[R SEEP.PIT If)[ Lf CWPOOLA
AI.IDATION JACK R. ALLEN SUPERVISING MECHANICALICALLENGINEER
CK. M.O. CASH
1'x9445 APR18 1 0 D 5.40~ q
APPLICATION FOR PERMIT
•ts-eas�I.ea
DIMION OF BUILDING AND SA.FM SEWER—SEWAGE DISPOSAL
Dopf1W-ni of C--iy Enubiew
CI�
Co"
of r� � �4DDREQSa
JOHN A.LAMBIE, COUNTY ENGINEER
m CARIZATT D.QRIFFIN, gur'T of BUILDINO LOCALITY
FOR APPLICANT TO FILL IN N oIT
LEGAL
DESCRIPTION LOT N0. . O M
MAIL
BLOCK -TRACTT //1S ADDRESS JJ
D OF LOT /� �Y • 0 ON LOTS / CITY TEL. X0.
USE OF
BUILDINGS DISTI ICT NO. GROUP MAP
BK
CONTRACTOR 4r[ r 7—
ADDRESS Y fr . . COInECnON DATA -
CITY TEL.NO. G �� STA N14– FZ DEPTH
MANHOLK Rr;FbU3CE
R01 NATE � LOWER
E
STRATION N0. .t .� q COUNTY _
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTM FROM /
PUBLIC SEWER B 9.50 1
Y. C RB .L. Y.L.TO P.L.
SEPTIC ANK, EPAGR PITO ��� ' _
PITS AND/ORDRAIXFIELD @ 3.00-
OVOFLOW,SEEPAGE PIT,DRAINFIEL CO. IMP. N0. JOB NOo
EITN.,CESSPOOL,DRYWELL, ANHOLE S 2.00
HQ SE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1.00 TRUNK PERMIT O. ROAD PERMIT NO
CONNECT ADDITIONAL BLDG.09 STATE ENCROACHMENT
DORIC TO HOUSE SEWER S 1.00 PERMIT NO.
ATER,REPAIR 0"AAYN HOUSE INDUSTRIALE� R ORDI POBAL
40 11.00 WASTE APPROVAL
CHARG63
CONNECTION CHARGE FEE
7 OW ErS s t 00
REIT-B
Aar HORMTION TOTAL FEE URbEYENT FEE
I HAVE AT T}IIS DATE A CONTRACT SMITH THE HEREIN NAMED CON- APPReOVPJS DATE INSPECTOR'SBIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER., tt'—' NEW HOUSESEWER - (p
SIGNED THIS---� & DAY OF Ias��,t CONNECT ADDITIONAL '
OWNER OE UILI)ING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ABp AND/OR PRAINFIELD
I HEREBY ACXNOWLEDG� THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY
WITH AL1 'CQUNTX ORDINANCES AHD !TATE LAWS REGUUTING /1�TER,REPAIR,SEWER OR
PLUYBIIi-d AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HE CERTIFY THAT I AY PROPERLY REGISTERED AHD/AR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUG AND
CALIFORNIA OR THATZPlPF-RTY.,,,,,Z�,,.
THE LEGA WNER OF T}1E ABOVEHOUSE
DESCRIBED RESIDENTIABACKFILL SEPTIC TANKSSIGItATURESEEP.PIT( ❑ CESSPOOLS Q
OF PERMITTI<5
J-OHN A_LAMBIE, Coy4TY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INBPgCrOR
Leo:3 6 2 8 ZR MAR 4.5 0 ka