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76A642D 0-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION em LD1NG
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. IENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO L IN CAO55 ST,
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ION LOT NO, I OWNEF /R��
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TRACT �/ J 3 y f ADDR
NO. OF BL GS.
LOT NOW ON LOT CIT S TEL. NO.
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ADDRESS /i YYy_ CONNECTION DATA
STATION ��
CITY BERTH
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SAE / UPPER
REGISTRATION NO, COTUTNTY MANHOLE REFERENCE '�` �Z C�taE�
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION` LENGTHUFROM
HOUSE SEWER CONNECTING TO CURB p,L. M.L.TO P.L.- 4
-
PUBLICSEWER @ S5,00 �"
SEPTIC TANK.SEEPAGE PIT OR P.C.NO, j O
PITS AND/OR DRAINFI ELD @ $10.00 rVIT
.NO. JOB NO. / �/ V
HOUSE SEWER CONNECTING TO PERMIT NO. ROAD PERMIT NO. p�
PRIVATE DISPOSAL SYSTEM @ 53.00 (G G w
CONNECT ADDITIONAL BLDG.OR Ary E/SEMENT RECORD.INSTR,NO. DATE Vj�
WORK TO HOUSE SEWER @ 33,00 ]V+
OVERFLOW SEEPAGE PIT.GRAINFIELD W
E%TN.,CESSPOOL.ORYWELL,MANHOLE@ $5.00
ALTER,REPAIR OR ABANDON HOUSE R ST,WIDENING
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
Li CONNECTION CHARGE FEE
AUTHORIZATIONrorAL FEE
.1 HAVE AT THIS DATE A CONTRACT WITH THE HERE NAME.
CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX IND DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY O 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL II
BUILDING OR WORK U
ADDRESS
SEPTIC TANK.SEEP,PITIS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DBAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS F RE BY LOS ANGLES COUNTY A O STATE OF SEWAGE DISPOSAL SYSTEM
C'CENSENIA OR NAT AM THE LEGAL NER O INTEND TO
RESIDE NI ��I.E.
DENTI P OPERTV. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE
OF FERMI BACKFILL SEPTIC TANKS
SEEP.FITT S) [I CESSPOOLS ❑
VALIDATIOROBERT A. WOOD
0SUPERVISING MECHANICAL ENGINEER
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