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76A642D APPLICATION FOR PERMIT
76A64 11
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 13U ILDING t
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Supt of Building /C.3
LOCA T"
C.�--'�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ( ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS �y�.
BK L PG
JyCONTRACTOR /j7 "-)-, /L
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
/ / ✓f
STATE MANHOLE REFERE NCE UPPER
REGISTRATION NO COUNTY L
NO DESCRIPTION OF WORK FEE .-�T PE OF CONNECTION LENGTH FROM _
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ S5 00 }
PC NO d
SEPTIC TANK SEEPAGE PIT OR O
PITS ANDOR DRAINFIELD @ $1000
CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO /�/y
PRIVATE DISPOSAL SYSTEM @ S3 00 `'' _/
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $500 d
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
_ INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY
OF 19_
OWNER NEW HOUSE SEWER ���
OWNERS AGENT- ��,(((///� ,�✓ CONNECTADDITIONAL 5 + 4
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND� TATE THAT THE ABOVE IS 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 REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESCRIBED RESIDENTIAL PROPERY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE ' BACKFILL SEPTIC TANKS ❑
ge SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LACC10 9 8 6 6 MAR 2 4 1 0 D 7.00—