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76A64 2D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engmeer ADDRESS
WILLIAM A JENSEN Sup t of Buildmg
LOCALITY 7
NEAREST �
_ R PP ICAN1 ! CROSS ST
E AL
SCRIPTION LOT O OWNER
/SO ,iw.; MAIL
1k, TRACT J O A ADDRESS
'� �/� 74
NO OF BLDGS /I
SIZE OF LOT jG:(a NOW ON LOT Y� CITY" TEL NO
USE OF F- �� t 'A16
BUILDINGS �A. L- �$. DISTRICT N GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
J V %
ADDRESS CONNECTION 15ATA
4 STATION ` DEPTH
CITY TEL NO a44- i tp
TATENTY MANHOLE REFERENCE / UPPER
REGISTRATION NO COULIOM[DI�
NO GESCRIP ON OF WORK FEE TYPE OFC TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y U B P L M L TOP L
PUBLIC SEWER ® 55 00
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD SIO 00 CO IMP NO ) JOB NO O_
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM @ 3300 V
CONNECT ADDITIONAL BLDG ORAFFIDAVIT wAlv[R [AS[M[NT RECORD INSTR NO DAT w
WORK TO HOUSE SEWER ® $300 O
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 V
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING LU
a
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT H
PERMIT NO Z
INDUSTRIAL ,
WASTE APPROVAL
OWNERS PERMIT $1 21 00 CHARGES
AUTHORIZATION TOTAL FEE I I
CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED X%NG DWELLING
TO THE PUBLIC S E APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS D Y 0� 19
OWNER OR !K<
NEW HOUSE SEWER
OW NERS AGE N / �( �C�_!y JA
CONNECT ADDITIONAL �l�st.. CST T.-✓';��,- 1
�1 BUILDING OR WORK
ADDRESS T
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH S APPLIC ON AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 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 DESCRIBE rRfESIDENTIAL PRO ERTY ABANDON HOUSE SEWER
SIGNATURE , �lI-r �p-, BACKFILL SEPTIC TANKS ❑
OF PERMITTEE 0��,4�� y" Lt{�-l� ��
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O ' CASH
Jh�,, i'�' SEP (� 1 C) p �1 0.0 0- `�