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APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES ' SEWER.-SEWAGE. DISPOSAL-
DEPARTMENT OF COUNTY-44tH
NGINEER -ICOUNTY
-
BUILDING AND SAFETY DTVISION - Bm LDInG" '-
IOHN A, LAMBIE. County E¢gmaor ADDRESS.
CASSATT D. GRIFFIN. Sup t of Building _ -
LOCALITY
NEAREST
FOR �PPLIC T ,TO, FILL INcRDss ST. i L ✓ Com,
LEGAL -
DESC AL LOT N n OWNER
BLOCK TRACT MAIL -
ADDRESS
.OF BLDGS. _
SIZE OF NOW ON LOT CITY TEL.NOT - "•�.
USE OF '
BUILD GS L DISTRICT NO. GROUP MAP
•-�� ,BK PG
co ,Acr �,� 3
ADDRES ,..</ CONNECTION DATA
CITY 15 - TEL.N0. � STATION � ' DEPTH /
MANHOLE REFERENCE UPPER
REGISTRATION NO. A
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q S 3.SEPTIC TANK.SEEPAGE PIT OR TYPE OF COyyBB ECTIONP. LENGTH FROM
. .
PITS AND/OR DRAINFIELD @ $3.00 Y. 6RB\ LM.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWEL L.MANHOLE /0 $2.00
HOUSE SEWER CONNECTING TOC'
N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR O
WORK TO HOUSE SEWER L$ $1.00 'TRUNK PERMIT NO. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ c3k00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
REIMBURSEMENT PEE
1 HAVE AT THIS DATE-A CONTRACT-WITH-THE HEREIN NAMED CON -'-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE IN PECTOR'S SIGNATURE
TO THE PUBLIC SEWER_
SIGNED THIS DAY OF ,G� 1 NEW HOUSE SEWER -
OWNER OR - �/J /J -- - - ----- -CONNECT ADDITIONAL- - - - ---
OWNERSAGEN +'/-� -/�LL (%l-7`Y BUILDING OR WORK
ADDRESS" SEPTIC-TANK,SEEP.-PIT(S)- - - -- --- — --
_ - - - - AND/OR'DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND.AGREE TO.COMPLY_ CESSPOOL O-DRYWELL ❑ - -- - - ^- ---^-WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I"HEREBY CERTIFY THAT' 1 AM-PROPERLY REGISTERED AND/OR SEWAGE.DISPOSAL SYSTEM -- - --- --- -
UC D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF - DISCONNECT PLUG AND
C ORNIA OR_THAT 1 AM, THE AL OWNE OF. ABOVE ABANDON HOUSE SEWER_
RIBE RESIDENTI PROPE BACKFILL SEPTIC TANKS 0
F
SEEP. PIT(S) 0 CESSPOOLS a)
P
®r VALIDATION• __- _ ROBERT A. WOOD .
ca. Myo. ` cAs_x/"] SUPERVISING MECHANICAL ENGINEER
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