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CEBOB 8-e9 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
" ADDRESS �l
IOHN A. LAMBIE. C..tF En
n ear _
CASSATT D. GRIFFIN, Suprt of Building LOCALITY <✓ A r
ST,FSd�L+OR APPLICANT TO FELL IN CROSS _
LEGAL
DESCRIPTION LOT NO. OWNER iG•Q -
BLOCK 71, MAIL
TRACT C --;2 cl ADDRESS X�G•wJ�
NO.OF BLDGS.
SIZE OF LOT rNOW ON LOT �� CITY TEL. N0.
USE OF
BUILDINGSL�-�..-E '4/ DISTRICT N0.I GROUP I
/BK MAP I PROC BY
l PGD
CO TOR Jr'oC� -r�te`
[, aooaess 1CONNECTION DATA
CITY TEL STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
N 0
0. 1 DESCRIPTION OF WORK FEE
HOUSE
PUBLICSEWER
CONNECTING TO @ $3.00 V
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT ORY. CURB .L. M.L.TO P.J.,
PITS AND/OR DRAINFIELD @ S3.00 �i
OVERFLOW SEEPAGE PIT. DRAINFIELD K^
Zr-0r -76
EXTN..CESSPOOL.DRYWELL @ 52.00
HOUSE SEWER CONNECTING TO P.C.NO
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. MP. NO. JOB N
CONNECT ADDITIONAL BLDG.OR a-{� TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER. REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DIS POS.L SYSTEM @ $1.00 RERMITNO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
[AUTHORIZATION TOTAL FEE �� REIMBURSEMENT FEE
VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
CTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
HE PUBLIC SEWER.
NED THIS DAY OF 19_ NEW HOUSE SEWERER ORCONNECT ADDITIONAL
ERS AGENT BU ILDING OR WORKRESS SEPTIC TANK,SEEP.PIT(S) _
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
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 1 AM THE LEGAL OWNER Of THE ABOVE
DESCRIBED RESIDENTIAL PRO RT BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITT
® VALIDATION ROBERT A. WOOD . .
C6 Y.g. DAstl SUPERVISING MECHANICAL ENGINEER
C� j��J�%G 6 7 � SEP 2 2 1 - 0 3.0 0