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DIVISION OF BUILDING AND SAFETY D 9SP®SAL - .
Department of County Engineer
-County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ;ADDRESS '
® CASSATT D. GRIFFIN, SUP'T OF BUILDING. LOCALITY
-..
FOR APPLICANT TO FILL CROSS ST.
LEGAL v D
DESCRIPTION LOT NO. OWNER
�.��a'aa ,' � MAIL pr
-, BLOCK ADDRESS O
NO. OF BLDGS. - .CITY TEL. NO.
SIZE OF LOT .T.�N7�-.5' NOW ON LOT i
USE OF DISTRIC`NN, GROUP MAP
BUILDINGS
BK PG
CONTRACTOR f
�a� CONNECTION DATA e
"'. ADDRESS ,® a4.vA�
�.. STATION _ DEPTH
CITY TEL. NO. ,D 6� J
i MANHOLE REFERENCE _ PER
Pf STATE R
` REGISTRATION NO. l � �• 7J ❑ COUNTY
NO.. DESCRIPTION OFOF VGbRK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM,
kP.L M.L. TO P.L.
d� PUBLIC SEWER @ $3.50 -3 S
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 - -
OVERFLOW SEEPAGE PIT,DRAINFIELD `/ P.. C. N0.-:
EXTN.,CESSPOO L,DRYW EL L,MANHOLE n $2.00 CO. IMP. N0. Q JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @, $1.00 TRUNK PERMIT NO. ROAD.PERMIT NO. "
CONNECT ADDITIONAL BLDG.OR STATE E ACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE _ INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 - WASTE APPROVAL
11-<'ARGES -�
CONNECTION CH E FEE- -
OWNER'S PERMIT $ 1 00
tl •REIMBUR , MENT FEE -
AUTHORIZATION TOTAL FEE 1q. 6 -1
1 -HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED'CON-
APPROVALS DATE INSPEC70RS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER.. NEW HOUSE SEWER ' "q:2, 5,9 " �(
SIGNED THIS DAY.O.F`'" 19- CONNECT ADDITIONAL
OWNER OR ) f. _BUILDING OR WORK - -
OWNERS AGENT �! SEPTIC TANK,.SEEP., PIT(S)
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL.[] DRYWELL[IAND 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG'AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 'AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) [I �
CESSPOOLS .
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION^ ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK. ti. 0.
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