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76808860 APPLICATION FOR T ,78A642D COUNTY OF LOS ANGELES ;
SEWER—SEWAGE DISPOSAL _ 1�
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE, County Engg��aeez c
WILLIAM A JENSEN, Sup t of BXgng LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL OWNER MAIL '
DESCRIPTION LOT NO
BLOCK TRACT ADDRESS `
OF BLDGS
SIZE OF LOT NOW ON LOT CITY �' TEL NO
USE OF
BUILDINGS / DISTRICT NO GROUP BK MAP PG PROCESS BY
CONTRACTOR X O
ADDRESS VVV CONNECTION DATA `
CITY TEL NO 4 ` STATION DEPTH
ATE MANHOLE EFERENCE _ UPPER
REGISTRATIO NO d COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF` ION LENGTH FROM /7
SEPTIC TANK SEEPAGE PIT OR Y CUR P L M L TO P L c�
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT_DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO-
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO -
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO O
WORK TO HOUSE SEWER @ $100 V „
SEWER REPAIR
SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT 07
PERMIT NO O
INDUSTRIAL V
WASTE APPROVAL Wa
CHARGES
OWNER'S PERMIT 2 0^^0 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE v REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESC BED EXISTING DWELLING APPROVALS DATE) INSPECTOR S SIGNATURE
TO THE PUBLIC SE E r— `� '.'
SIGNED THIS Y OF 19 NEW HOUSE SEWER a/ r�G
OWNER OR \ CONNECT ADDITIONAL / r
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S) -
_ _ AND/OR DRAINFIELD
1 HEREBY, ACKNOWLEDGE T AT 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 SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '♦
LICENSED AS REQUIRED Y LOS ANGELESCO NTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH M THE GA 0 ER OF THE ABOVE e
DESCRIBED RESIDEN A P OPERTY +'" SEEPFI LL SE
PIT(S)P❑ CESSP00❑L�!
SIGNATURE
OF PERMITTE +
OF OLMATION ROBERT A WOOD
m o CASH SUPERVISING MECHANICAL ENGINEER
7068t'cl Jm 151 = C :00