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S&E-663 11-55
DIVISION OF BUILDING AND SAFETY SOWER-SEWAGE D.ISPOSAL
N Department of County Engineer
County.of Los-Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS"
® - CASSATT D. GRIFFIN, SUPT OF BUILDING 4' LOCALITY -
v "
FOR APPLICANT-TO FILL IN CROSS ST. '
LEGAL WSJ .aZiPW 24-,4.S D
DESCRIPTION LOT NO. + OWNER al
MAIL
BLOCK TRA ADDRESS
r NO. OF BLDGS. CITY TEL. NO. "
SIZE OF,LOT NOW ON LOT USE OF -
BUILDINGS DISTRICT N0. GROUP' MAPBK
-
CONTRACTOR
ADDRESSCONNECTION- DATA - -
61
STATION DEPTH
CITYItz TEL. NO• - D - •MANHOLE REFERENCE
. ®
R
oo2 �❑ STATE
REGISTRATION NO. /vt /
COUNTY t -
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECT10 LENGTH FROM
.HOUSE SEWER CONNECTING TO 1
PUBLIC SEWER @ $3.50 ' -P.L. M.L. P.L. ;1
SEPTIC TANK,.SEEPAGE PIT OR - - ,•
PITS AND/OR DRAINFIELD n $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P:C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE t?n $2.00 CO. IMP. NO. / 933 1.0B NO. '
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL'SYSTEM @ $1.00 TRU ERMIT NO. - ROAD PERMIT N0. -
CONNECT ADDITIONAL BLDG.OR STATE ENCR_CXe4&QNT -
WORK TO HOUSE SEWER n $1.00 PERMIT NO. '
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM a .$1.00 . WASTE APPROVAL -
' CHARGES
C 0 N N E CeeN CHARGE FEE -
OWNER'S PERMIT 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
APPROVALS DATE INSPECTOR'S SIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - -TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THISDAJ}Y 19 CONNECT ADDITIONAL:
OWNER OR / ` / -- BUILDING OR WORK - - -
OWNERS AGENT'-- �/ - SEPTICTANK,SEEP, PIT(S)
ADDRESS .AND/OR DRAINFIELD
I. HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL'❑
AND STATE THAT THE ABOVE- IS CORRECT AND AGREE TO'COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER 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 COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT J AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL RO,PERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS !
SIGNATURE I "
—
OF PERMITTEE - -
JOHN A. LAMBIE, COUNTY ENGINEER ALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
M. 0.