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76AG41°'B2 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION - BUILDING
JOHN A. LAMBLE, County Engineer ADDRESS WILLIAM A. JENSEN, Supt of Building _ F771
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `R°BB ST
EGAL
OESC RIPTION LOT NO. �C'[ ` OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BL Go. _
-SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DIBTRICTNO. GROUP MAP PROCESSEO BY
BK PG
CONTRw CTOR ) // JJ Nyjx_�:r�
ADDRESS J ( J�n , CONNECTION DATA
//Y[[// STATION BE—
CITY TEL.
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.REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE VTC OWER
NO. DESCRIPTION OF WORK EE TYPE OF CO .ION LENGTH FR6M a
HOUSE SEWER CONNECTING TO ^ J./'f Y. URB P.L. M.L.TO P.L. j A O
PUBLIC SEWER a 55.00 V
BEPT IC TANK.BEEPAGE PIT OR ]
PITS AND/OR ORAINFIELD -i'_0 0
I000 CO.IMP.NO. J Z JOB NO. v
IX
-- BE SEWERCONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIV AT.
DISPOSAL SYSTEM @ 33.00 H
CON NECT NO DITION AL BLDG.OR AFFIDAVIT •IV ns[e[ RECORD.INSTR.NO. DATE
W O RK TO NO
USESEWE R $3,00 a
OVERFLOW SEEPAGE PIT.GRAINFIELD ELD [n
E XTN.,CESSPOOL.DRYW E LL,MAN ROLE 55.0° Z
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER.OR DISPOSAL SYSTEM @ $3.°0 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMITs z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
ITHAVE AT THIS DATE A CONTRACT WIH THE HEREIN NAMED CON- REIMBURSEMENT FEE -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECT0 SSIGNATURE
SIGNED THIS DAY OF 19_ .�
OWNER OR - - NEW HOUSE SEWER —
OWNERS AGENT
CONNECT A NAL
BUILDING DRR WORWORK
ADDRESS
SEPTIC TANK,GRAINFIELD SEEP,PIT(G)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION pry0/OR DRAINFIELD
AND STATE THAT THE ABOVE IS LAND S AND AGREE E COMPLY
WITH ILL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND.SEW ERS. CESSPOOL ❑ DRYWELL ❑
*I HEREBY CERTIFY THAT I -AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER°R
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LE L OWNEF O AND INT TO
.'DISCONNECT PLUG AND
RESIDE IN. THE AS VE B ID NTA
PROPERT _
t ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE /
_ - SEEP.PIT(S) ❑ CESSPOOLS
wALIDATION Ro a A. woo -
rSUPERVISIN MECHANICALENGINEER
7JM.O. CASH
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