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APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY S EW E R-S E WAGE D I S POSA L
Deportment of County Engineer '
' County of LOS Angeles ' BUILDING 9 ;Z -� , �'V1 G ��
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS il
® CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY 4E KP L_
FOR APPLICANT TO FILL IN CROSS ST. 25 46Z ELS
LEGAL
.DESCRIPTION' LOT NO LIQ OWNER
BLOCK - TRACT MAIL
��1 f b 7I ADDRESS
NO OF BLDGS CITY TEL. NO
SIZE OF LOT - .NOW ON LOT
USE OF DISTRICT NO I GROUP. I
BUILDINGS PG
MAP
CONTRACTOR S rV•�;;
ADDRESS—JG S A CONNECTION DATA
STATION DEPTH
CITY �Q �(�.�- TEL. NO t "Ii -
MANHOLE REFERENCE' _ � Ii UPPER
STATE
REGISTRATION NO lS COUNTY ,
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER - @ $3 50 C ) Y CURB M L TOP L
17
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 JOB NO
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT- - -
WORK,TO HOUSE SEWER @ $1 00 PERMIT NO - -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL - -
SEWER OR DISPOSAL SYSTEM _ @ $1 00 WASTE APPROVAL'
CHARGES
CONNECTION_ CHARGE FEE _
OWNER'S PERMIT g 1 00 -
AUTHORIZATION TOTAL FEE S� REIMBURSEMENT FEE
1 4p
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR-S-SIGNRE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER n,
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL -
OWNER _OR BUILDING OR WORK' -
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL E) DRYWELL El -
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 DISPOSALSYSTEM
I HEREBY CERTIFY TH I A PROPERLY REGISTERED AN
LICENSED AS REQUIRED Y L ANGELES COUNTY E OF DISCONNECT PLUG AND
CALIFORNIA OR THAT A HE LEGAL���yyCC'''+'+�a�� F THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTI P ERTY_, BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS) LICESSPOOLS-0OF PERMITTEE
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JOHN A LAMBIE. COUNTY ENGINEER ALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
d 0 CASH '
'LAC.0 5 1 1 9,� DEC 1 6 4, A.50 2
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