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D 4 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING L—� G �) �L
JOHN A. LAMBIE. County Engineer AODRE.- J
WILLIAM A. JENSEN, Supt of Building
LOCALITY L-
NEARESST
FOR APPLICANT TO FILL IN "OSB ST.
LEGAL /
DESCRIPTION LOT NO. OWNER N y_
MAIL
BLOCK TRACT A AO DRE6B
NO. OF SLOGS. /j 1
SIZE OF LOT NOW ON LOT CITY C-) I TEL. NO,
USE OF DISTRICT NO. GROU MAP PROCESSED BY
BUILDINGS
/ BK PG
CONTRACTOR c'/'0
ADDRESS _ CONNECTION DATA
CITY _� NO. �QL STATION /I DEPTH
REGISTRATION NO.
COUT.NTY MANHOLE REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH PROM O
HOUSE SEWER CONNECTING TO •— Y. CURB L.
M.L.TO P.L.
PUBLIC SEWER ® $5.00
SEPTIC TANK,SEEPAGE PIT OR P,C,NO.
PITS AND/OR DRAINFIELD 3I0.00 CO.IMP. NO. JOB NO. 7, I `J d
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT RAIVEV VAVNNxT RECORD.INSTR.NO. DATE K
WORKTO H OUSE SEWE R ® E3.00 0
OVERFLOW SEEPAGE PIT.GRAINFIELD U
ETTN„CESSPOOL.DRYWELL.MANHOLE® 55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING W
S EWER OR DISPOSAL SYSTEM $3.00S
TATE
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z ao CHARGES
AUTHORIZATION TOTAL FEE ) CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEO CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW 'c APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS=D¢Aj OF 19� V
OWNER OR ///�� NEW HOUSE SEWER SIP
OWNERS AGENT CONNECT ADOITIO NAILIf
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION PITIS)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY "ND/Ofl DRAINFIELIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE OE RIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PL1IB) ❑ CESSPOOLS ❑
CK
ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
LACo 1 7 0 2 KplY 17 1 0 D 7,0 0, c