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CE8088-59 APPLICATION FOR PERMIT -4?9W ,PO-C
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
AO DRESS
JOHN A. LAMBIE. County Eogioeer
CASSATT D. GRIFFIN. Supt of Building LOCALITY 7
NEAREST
FOR APPLICANT TO FILL IN ceass sr.
LEGALa-
DESCRIPTION LOTK OWN T�///AJD/J''07 /V /
MAIL
BLOCK TRACT/ (¢ ADDRESS
NO,OF BLOBS.
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGSK PG
DISTRICT NO. GROUP MAP PROCESS BY
CONTRAC n � 8 }
ADDRESS V CONNECTION DATA
CITY TEL.N STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. OUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK.SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR GRAINFIELD @SS.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.. CESSPOOL DRYWELL @ 52.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1,00 CO.IMP, NO, JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
O.
_ PERMIT IA
_ INDUSTRIAL
� WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z UO _ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 0-0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER /
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I 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 SEWER EM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT ABANDON HO PLUG PLUGD
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L�ROPERIY. BACKFILL BE TAN KS ❑
51 GNATURE SEEP. PIT{,)
❑ CESSPOOLS ❑
OF PERMITTE -«�' B-00
®" YALIDAT16N ROBERT A. WOOD
. ._._ CIL M.O� u$tl SUPERVISING MECHANICAL ENGINEER
Lr:1�237 � � 1uip1op 3 .00
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