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S&E-689 11.55 6�1 11 � H U C A T M N FOR P E R O C%II� FI
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DIVISION OF.BUILDING AND SAFETY SEWER—SEWAGE mS P®$A L
Department of County Engineer .f,
County of LOS Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
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FOR APPLICANT TO FILL XIN. CROSS ST.
LEGAL ® >
" DESCRIPTION LOT NO. OWNER
MAIL
i. BLOCK ADDRESS ,d '
NO. OF BLDGS. CITY TEL. NO.
SIZE OF LOT JA �;�.,� NOW ON LOT
USE OF DISTRICT NO, GROP MAP
BUILDINGS BKS Y G .
CONTRACTOR �✓ tl ..� .
CONNECTION DATA�,��6� a
ADDRESS
STATION D&TH t
CITY TEL. N0. ®
MANHOLE REFERENCE S7,1
/ V �® , ❑3 STATE
- REGISTRATION N0. COUNTY .
NO. DESCRIPTION OF WORK FEE
TYPE OF CONN.ECTIO LENGTH FROM �$ d
PUBLIC HOUSE S EWES CONNECTING TO @ $3.50 ',� J-0 ,;`: —zj
P•L'. M.L.TO P.L. p(,�
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00 H
OVERFLOW SEEPAGE PIT,DRAINFIELDP. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 :� CO. IMP. N0, 3-3 JOB NO.
HOUSE SEWER CONNECTING'TO -
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK MIT NO. ROAD PERM 0.
CONNECT ADDITIONAL BLDG.OR STATE ENCRO - - -
WORK TO HOUSE SEWER @ $1.00 a PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION RGE FEE
OWNER'S PERMIT $ 1 00 . ;
AUTHORIZATION TOTAL FEE Sb REIMBURSEMENT FEE
I,HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDCON- APPROVALS DATE INSPECTOR'S SIGNATURE'
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER '
SIGNED THIS,•: D9 OF 1 9 19 CONNECT ADDITIONAL
,5 OWNER OR BUILDING OR WORK .
OWNERS AGEN� .
SEPTIC TANK,SEEP, PIT(S) '
ADDRESS / AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
't. 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 n ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ,
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
.r SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER ... m VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N. 0. CASH
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