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CEBOB 3-02 APPLICATION FOR PERM1
76AS420 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / q
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS •�
COLEMAN W. JENKINS. SUPUI
T. OF BUILDING LOCALITY / , C. /
' NEAREST � II
FOR APPLICANT TO FIL IN GROSS ST.
EGAL
DESCRIPTION LOT NO. OWNER • O L
MAIL
BLOCK TRACT ADDRESS A
NO. OF BLDGS.
fff
SIZE OF LOT c NOW ON LOT CITY TEL. NO. / S
U5E OF �'JA DISTRICT NO. GROUP MAP PROCESSEO BY
BUILDINGS J
T BN PG
CONTRACTOR
L Y Py �pOY Y'P CONNECTIO DATA
ADDRESS y� �f
p 6 PPE
STATION/�' gT � DEPTH
CITY N TEL. NO.7 J,
STATE ;/ O CLP55 G MANHOLE REFERENCE
LICENSE NO.
NO. .DESCRIPTION OF WORK FEE TYPE OF gill, TION LENGTH FROM �� }
tI HOUSE SEWER CONNECTING TO O Y. CURB R.L. M.L.TO P.L. d
I PUBLIC SEWER ® 55.00 5:10 P,C.NO. O
SEPTIC TANK.SEEPAGE PIT OR �_ / , JOB NO. LJ
PITS AND/OR DRAH.FIELD ® 510.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNH PERMIT NO. ROAD PERMIT NO. G
PRIVATE DISPOSAL SYSTEM ® S.O. u O
CONN ECT ADDITI ONA L BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ® $3.00 O O W
OVERFLOW SEEPAGE PIT.DRAINFIELO 1
E%TN..C ESSPOO L,DRYW ELL.MANXOLE� 55.00 SpI
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Z
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCROACHMENT -
PERM IT NO,
INDUSTRIAL
WASTE APPROVAL
OWR
NES _PERMIT s z oo CHARGES
AUTHORIZATION TOTAL FEE A 1' CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'SSIGNATU RE
SIGNED THIS DAY OF -Is—
OWNER
OWNER OR NEW HOUSE SEWER 5 _
OWNERS AGENT_ CONNECT ADDITIONAL r
BUILDING OR WORK
OGRESS
SEPTIC TANK.SEEP.PITIS)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ARD/OR GRAINFIELD
AND STATE THAT TME ABOVE ICOAND AGREE COMPLY
WITH ALL COUNTY OROINPNCE AND SS AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REDUIRED 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
RESIBE IN. THE ABOVE ADESCRIB RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE L y /lIM BACKFILL SEPTIC TA NNS ❑
OF PERMITTEE _^ ` SEEP..*PITIIs) LlCESSPOOLS /
VALIDATION----) JACK A. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAC07 0 9 7�- OCT 31 1 0 D 1 0.00-
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