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CEBDB 10-62 . - APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Dy� DBv�F y
JOHN A. LAMBIE• County Engineor ADDRESS O
WILLIAM A. JENSEN. Sup'1 o1 Building
LOCALITY /
NEAREST
FOR APPLICANT TO FILL °ROSS 5T'
LGAL -Ga�etE•- A p�/�!
DESCRIPTION LOT NO. OWNER /� Ovr-✓ (/(/- .'TY__LPJ_)._L/ e U
MAIL /• ---JJ}+++---
oLOCK TRACT ADDRESS /J� (�
NO. OF
SIZE OF LOTS j[•A�-�( O NOW ON LOT �(JV (1 CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS -e�L r �i�r9GC
CONTRACTOR �. /__ J ,/ • ({ V �l �PG ^�
ADDRESS V CONNECTTON DATA C J\
CITY TEL. NO. STATION DEPTHSTATE /J
R ® of
COUNTY MANHOLE REFERENCE q T (tP �•
�J G LOWER
REGISTRATION NO. a
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM O
XOVSE SEW ERCONNECTING TO Y. CURB P.L. M.L.TO P.L. V
PUBLIC SEWER ® $
5.00 P.C.NO. yr
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 49 $10.00 CO. IMP. NO. J06 NO, {`O,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, y
PRIVATE DISPOSAL SYSTEM n6 $3.00 LLLLLLIII
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT G[a[nT RECORD.INSTR.NO. DATE d
WOR K TO HOUSE SEWE R 33,00
OVERFLOW SEEPAGE PIT,GRAINFIELD I L•
E XTN.,CESSPOOL,DRYWELL.MANHOLE® 35.00
ALTER.RFP .+ eppgppN T. ING SEWER HOUSE
OR_gIS cg�5YY EM $3.00 �~ STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTEAPPROVAL
CHARGES
OWNERS PERMIT s E2 oD —
CONNECTION CH.)RGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT )
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK 1(1
SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
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 D15POSAL SYSTEM
CALIFORNIA OR THAT 11AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE ESCRIBEO RESIDENTIAL
/V// ABANDON HOUSE SEWER
SIGNATURE Ma�� BAOKFILL SEPTIC TANKS ❑
OF PERMITTEE- Y '-�[
SEEP,PITISI ❑ CESSPOOLS ❑
/VALIDATION ROBERT WOOD '
(ls// SUPERVISING MECHANICAL ENGINEER
CK, M.0. CASH
L,,kCo8 2 -9 3-0 FEB 5 1 0 D 5,00~ v