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APPLICATION FOR PERMIT 1
8&E 8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engmeer
County Of Los Angeles BUILDING - /�e
JOHN A LAMBIE COUNTY ENGINEER J_ADDRESS / � v
® CASSATT D GRIFFIN SUP T OF BUILDING' LOCALITY / �� to
NEAREST
FOR APPLICANT TO FILL IN CR
CRASS ST _ V
LEGAL /G/ / ,,` St✓ / v*�^ •� '�
DESCRIPTION LOT NO /V �+ OWNER N
BLOCK TRACT �j�r"�/ FFF---lll ADDRESS ��
NO OF BLDGS ,.. -
SIZE OF LOT J 6 NOW ON LOT C"' 1 L
USE OF DISTRICT NO GROUP MAP
BUILDINGS
BK PG
CONTRACTOR A �rJ
CONNE TION DATA
ADDRESS04
+'� ,/
�� STATION i V- 3/.i a DEPTH 6
CI S /'vriQ i
MANHOLE REFERENCE UPPER �
T
REGISTRATION NO [ICOUNTY
"
NO DESCRIPTION OF WORT FEE
TYPE OF ECTION LENGTH FROM
HOUSE SEWER CONNECTING TO
Y C PL M L TOPL
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO 3 ! JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO !f[J
CONNECT ADDITIONAL BLDG OR ,�f J STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 [T(/` PERMIT NO
ALTER REPAIR OR ABANDON HOUSE - INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT-FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DES ED EXISTING DWELLING _
TO THE PUBLIC SE - NEW HOUSE SEWER
1.0
SIGNED THIS AY OF CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNO LEDG THAT I HAVE READ T PPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND E TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE L WS REGULATING ALTER,REPAIR SEV4gR OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES UNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM E LEG NER OF THE ABOVE
DESCRIBED RESIDEN PRO R�Y BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS �b S
OF PERMITTEE
JOHN P: LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK tl O C SH
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