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A642D
76A642 0-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FEAE
JOHN A. LAMBIE, County Engineer 70
WILLIAM A. JENSEN, Supt of Building °�-
FOR APPLICANT TO FILL IN
LEGAL
—DE,CRIPTION LOT NO. T7 OWNER
/ / MAIL
J'
BLOCK TRACT ! ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT T
TEL. NO.
USE OF T NO. GROUP MAP PROCESSED BY
BUILDINGS
c�(/ BK PG 7
CONTRACTOR '/ADDRESS Zj' G CONNECTION DATA
N DEPTH
NO.7 �y / ❑ SLE REFERENCEREGISTRATIONNO. 6� / ❑ ' LOWERNO. DESCRIPTION OF WORK FEE E OF CO TION LENGTH FROM
HOUSE SEWER CONNECTING TO URBP.L. M.L.TO P.L. .-PUBLIC SEWER @ $5.00 C'
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 . NO. JOB NO.HOUSE SEWER CONNECTING TO /y `JPRIVATE DISPOSAL SYSTEM @ $3.00 PERMIT NO. ROAD PERMIT NO. 4 Q -7 ♦�
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE�-
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE QO CONNECTION CHARGE FEE
'IHAVE AT THIS DATE ATTTTTTJJJJJJiiiiiiE CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNEC ABOVE D CIRED EXISTING DWELLING
TO THE PUBLIC SE I APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT ^
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRE BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M TH LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DES BED RESIDENTI RO PERTY. ABANDON HOUSE SEWER
SIGNATURE El PERMITTEE BACKFILL SEPTIC TANKS
SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATIOpi� ROBERT WOOD
( ' SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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