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76A642D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A LAMBIE County Engineer ADDRESS /
WILLIAM A JENSEN Sup t of Building �•
LOCALITY
f-NEAREST
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FOR APPLICANT TSO( FILL IN CROSS ST
LEGAL �i�r �H/ Y��GI�/ '
DESCRIPTION LOT NO OWNER
s MAIL
BLOCK TRACT �J ADDRESS ` ///W;J zn,,V qNO
SIZE OF LOT NOW OON LOTS �""' CITY /Jl /�gEL NO (ice/.�
USE OF /� DISTRICVOIG ROUP I BK MAP PROCESSED BY
BUILDINGS fPG ///CONTRACTOR � 1 . O� L �0 � e j
ADDRESS �/,j p�,/�/�//�,/� �Cj�j GJi�CJ/� h CONNECTION DATA
CITY/��l�GjLI/e TEL NO 4C�_11"r/ STATION �� /L� DEPTH /
/ /$,p 4e a STATE MANHOLE REFERENCE / c..
REGISTRATION NO (0 �7 �F COUNTY / 6_5 l R
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM c/
HOUSE SEWER CONNECTING TO Y SPrJJRLE CURB P L M L TO P L 0 }
PUBLIC SEWER @ 55 00
P C NO d
SEPTIC TANK SEEPAGE PIT OR �j
PITS AND/OR DRAINFIELD @ S10 00 CO IMP NO Lf-• JOB NO Q
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVII [AIIMINT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT DRAINFIELD U
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s
AUTHORIZATION TOTAL FEE A J CONNECTION CHARGE FEE CHARGE
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
OWNER /�/ �� 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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS I CESSPOOL El DRYWELL ❑
IHEREBY 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 ABOV ESCRIBED RESI N OPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP PIT(S) ElCESSPOOLS
1VALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
LACO3 7 6 11 SEP15 1 1 0 2 5.00
6A642 D
76A8420-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FROIS
G
JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building 7 �
Y /T
FOR APPLICANT TO FILL IN T
LEGAL
DESCRIPTION LOT NO 4 OWNER
// ` MAIL �-
BLOCK TRACT /(�a7 � ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
PG
CONTRACTOR
ADDRESS fjp SVG [���jC IJj CONNECTION DATA
CITY TEL NO lj+�y;J �/ %✓ STATION �....r + EPTH 7 r
STATE ^J UPPER
REGISTRATION NO ���C�¢ COUNTY MANHOLE REFERENCE (,./ C OV A a
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION J LENGTH FROM l i
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L P� }
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR Op P C NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO14-16 JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO � � ix
PRIVATE DISPOSAL SYSTEM @ $300 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVE0
R EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ S300 V
OVERFLOW SEEPAGE PIT DRAINFIELD LU
EXTN CES SPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE po CONNECTION CHARGE FEE
IHAVE 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 / �Jy' 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 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 I A THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV E CRfSED RE57AL—PROPERTY ABANDON HOUSE SEWER
SIGNATURE / BACKFILL SEPTIC TANKS ❑
OF PERMITTEE
SEEP PIT IS) El CESSPOOLS ❑
VALIDATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
- CK
LJCO
3 7 6 0 SEP 15 1 0 D 7.0 0-