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APPLICATION FOR PERMIT
]689420D
COUNTY OF LOS ANGELES SEWER—SEWAGE DI OSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION tADESS
LDING p/ �)
JOHN A. LAMBIE. County Engineer EIREWILLIAM A. IERSEPI. Sup'1 0[ Building ITYSFOR APPLICANT TO FILL IN ' BT.
LEGAL
°ESC RIPTION LOT NO. OWNER
MAIL
BLOCK TRACT D V ADDRESS
NO, OF BLOTS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
UU ILDING$
iT,ION
RICT NO. GROUP MAP PROCESSED BY
In^/ I ,� BK PG
CONTRACTOR ,t--
0"
, �' ^
ADDRESS L� Ct / Y ff�� CONNECTION DATA
CITY .� TEL. NO.` DEPTH
{ > IGTSTATE (%
i L / lJ COUNTY MANHOLE REFERENCE ,
REGISTggTION NO.
NO.
DESCRIPTION WORK FEES A r
PE OFC NEC 1 LENGTH F OM
HOUSE SEWER CONNECTING TO T U P. M.L.TOP J
PUBLIC SEWER @ E5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. (J
PITS AND/OR DRAINFIELD @ SIO.00
HOUSE SEWER CONNECTING TOI TRUNK PERMIT NO. ROAD PERMIT NO. //
no
PRIVATE DISPOSAL SYSTEM $3.00 TTT
CONNECT ADOITIO NAL B LDG.OR AFFIDAVIT Ary su[x RECORD.INSTR.NO. DATE
WOR K TO HOUSE S EWE R $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
E%TN..CESSPOOL.ORTWELL.M A NH OLE @D 55.00 f'
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING Z
SEW OR OISP SAL 5 Si @ S3.00 STATE ENCROACHMENT
010 PERMIT NO.
INDUSTRIAL
WASTEAPPROV
OWNERS PERMIT s C ARGEB
CONNECTION CHARGE FEE >+
AUTHORIZATION TOTAL FEE J
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TO THERP UBLCCONNECT SEWER. APPROVALS
ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'SSIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR �- yam NEW HOUSE SEWER
OWNERS AGENT_ j� �V / CONNECT ADDITIONAL
I BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.FIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RE PAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. ANO INTENp TO DISCONNECT PLUG AND
RESIDE IN, THE ABVE ESCRIUEO RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE / ❑
UACKFILL SEPTIC TANKS
OF PERMIT _ SEEP,PITISI ❑ CESSPOOLS ❑
VALIDATIONI ROBERT A. WOOD
CK. M.O, cAcgSlH SUPERVISING MECHANICAL ENGINEER
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7686420 AP RMI T
PLICATION FOR PE
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1111
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / y !
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building �J
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
DESLEGAL
CRIPTION LOT NO. I OWNER
u1 {{{'--- MAIL
BLOCK TRACT '/ ADDRESS
NO. OF SLEDS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
BUILOF
DINGS �{y�l DISTRICT NO. R[�YP MAP PROCEsBED BY
/tel K PG .
'_5_
ADDREss �'; sr CONNECTION DATA
CITY t-1A– TEL. NOL Q K _ T DEPTH
STATE UPPER 1
G I'f� MANHOLE REFERS NCE
REGISTRATION NO, 1 - D LJ COUNTY [ 1�
NO. DESCRIPTION OF WORK FEE TYP O NECTI LENGTH FRO / a
HOUSE SEWER CONNECTING TO RB M.L.TO P.
O
PUBLIC SEWER @ S5.pO
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. V
PITS AND/OR DRAINFIELO @ !10.00 CO.IMP.NO. J JOB NO.
HOUTRUNK PERMIT NO
SE SEWER CONNECTING TO /y p C
PRIVATE DISPOSAL SYSTEM @ $3.00 , ROAD PERMIT NO. O! / IO.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wgvu u5[x[xr RECORD.INSTR.NO. / JOATE
WORK TO HOUSE 5EWER 0 $3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE So.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING _
SEWER OR DISPOSAL SYSTEM 0 $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WA EAPPROVAL
GES
OWNER'S PERMIT 5 z 00
AUTHORIZATION I TOTAL FEE lL/� CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AIMED COIN-- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOJSSIGNATURE
SIGNED THIS DAY OF 19_
OWNER / NEW HOUSE SEWER
OWNERS
AGENT_� CONNECT ADDITIONAL
OGRESS j!rBUILDING OR WORK
SEPTIC TANK,SFIELD T1s)
1 HERESY STATE A KNOWLEDGE THAT I HAVE READ TH15 APPLICATION PND/OR DRAINFIELO
AND STATE THAT THE ABOVE 15 CORRECT TE AGREE E COMPLY
WITH ALL COUNTY ORDINp NCEs AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT pM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE A V DESCRIBED RE51DENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT ISI ❑ CESSPOOLS ❑
VALIDATION-,, ROBERT A. WOOD
M.0.
CK. M.0. /c.ASH SUPERVISING MECHANICAL ENGINEER
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