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TO-63
76A642D , APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS t 3
WILLIAM A JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS
LEGAL
DESCRIPTION LOT NO l OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDG
S
SIZE OF LOT NOW ON LOT t CITY J TEL NO
USE OF / DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
`-�+ B K PG / //J
CONTRACTOR ' _JI QAl
C \!1 R O
ADDRESS �VVJ" CO ECTION DATA ���//11rr"��
CITY / TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L }
PUBLIC SEWER @ $5 00 d
SEPTIC TANK SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 ^
CONNECT ADDITIONAL BLDG OR l� A FIDAVIT WIVER E411MINT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $300 V v 1
OVERFLOW SEEPAGE PIT DRAINFIELD G1J
EXTN CESSPOOL DRYWELL MANHOLE @ $500 �j�
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WID I C?.Y N
Z
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE ,,5, CTfJ CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR f NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESSD BUILDING OR WORK
SEPTDIC R TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THI APPLICATI AN �ODRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP Y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS I CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THA AM PR LY GISTERED AND/OR ALTER REPAIR SEWER OR ,
LICENSED AS REQUIRED LOS A GLE UNTY AND STAT F SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LE AL O R OF N
RI
TO DISCONNECT PLUG AND
RESIDE IN T BO�ESCRIBED RE IAL RTY
ABANDON HOUSE SEWER
SIGNATURE C�
OF PERMITBACKFILL SEPTIC TANKS ❑
T ❑
SEEP PIT(S) ❑ CESSPOOLS
LIDATIO \ ROBERT WOOD
CK M o (CASH/} SUPERVISING MECHANICAL ENGINEER
LAIC o6 0 6 3% NOV 2Q 1 0 D 5,0 0- w