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76A642 0-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
Ua�JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Buildbng
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT Z ADDRES evQ
/�
NO O BLDGS
SIZE OF LO7 Q NOW ON LOT CITIli TEL NO
USE OF r
GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRACTORCONNECTION DATA
ADDRESS ON DEPTH
EL NO go rTATE UPPER
REGISTRATION NO / COUNTREFERENCENO DESCRIPTION F WORK FEE OF CO ION LENGTH FROMHOUSE SEWER CONNECTING TO J� URBPL M LTOPLPUBLIC SEWER SS 00 Q'I! PC NO
SEPTIC TANK SEEPAGE PIT OR O L JOB NO O
PITS AND/OR DRAINFIELD @ SIOo0HOUSE SEWER CONNECTING TO RMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ 33 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEM[N7 RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300
V
OVERFLOW SEEPAGE PIT DRAINFIELD Uj
EXTN CESSPOOL DRYWELL MANHOLE $5 00 H
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE J CONNECTION CHARGE FEE
REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER c��� DATE INSPECTORS SIGN TU E
SIGNED THIS DAY OF //J 19W
OWNER OR OF NEW HOUSE SEWER
OWNERS AGENT l�L� CONNECT ADDITIONAL r
C BUILDING OR WORK
ADDRESS 3
SEPTIC TANKSEEP PIT(S)
I HFREBY ACKNOWLEDGE THAT I HAVE READ IS 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 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 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLI '
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L';LO 8 4 5 6 llstY 5 1 `) D 7.0 0'
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