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76AB420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
III S�
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
/ MAIL `
BLOCK TRACT ' (vim ADDRESS
BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR
ADDRESS L) CONNECTION DATA
CITY NO ^ STATION S DEPTH ,
f1 /y}�TATE
REGISTRATION NO. y LJ COUNTY MANHOLE REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO Y. CURB
M.L,TO P.L.
PU BLIC SEWER @ $5.00
SEPT ANE/O .SEEPAGE PIT OR JO NO a
PITS AND/OR DRgINFIELD $10.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADO ITIONAL BLDG.OR AFFIDAVIT elv SENERT RECORD, INSTR.NO. DATE
WORK TO HOUSE SEWER a $3.00 O
OVERFLOW SEEPAGE PIT,DRAMFI SLD V
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $5.00 Iy
ALTER, REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT It z 00
AUTHORIZATION TOTAL FEE ' CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THEPV BLIC SEWE , APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF 1916
OWNER OR NEW HOUSE SEWER
OWNERS AGENT-
OWNER
/ 'p CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTICTANK.S T(S)
HEREBY ACHNOW EE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFHELD
IELD
AND STATE THAT THE ABOVE I$ CORRECT AND AGREE COMPLY
WITH ALL COUNTY OROINgNCES AND STATE LA WS REE GULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBEO RBEI!TIAL :j R ABANDON HOUSE SEWER
SIGNATURE `,/
OF PERMITTEE // BAC K FI LL SEPTIC TElANKS
SEEP,PIT 15) ❑ CESSPOOLS El
OVALIDATION ROBERT WOOD
I/
SPERVI SING MECHANICAL ENGINEER
CK. M.0. CASH
Lr`'11o1 7 0 5k� PAY17 1 0 D TO 0~ °f