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CES08-8 APPLICATION ION FOR PERMIT 7
ceeoe-e-sa COUNTY OF LOS ANGELES ` 1
" SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION JADDRESS
UILDING
�97-o
JOHN A. LAMBIE, County EngineerCASSATP D. GRIFFIN, Supt of BuildingOCALITYEAREST
FOR APPLICANT TO FILL IN CROSS STLEGAL .
DESCRIPTION LOT NO. IO s OWNER ,
BLOCK TRACT MAIL
A DR S dPeel0
NO.OF BLDGS. '
SIZE OF LOT NOW ON LOT CITY TEL.N0.
USE OF
BUILDINGS - DISTRICT NO. GROUP BK PG MAP ROCESSED BY
CONTRACTOR�'``/l
ADDRESS f CONNECTION DATA
CITY LG2 / TEL. NO. 7& �Plf STATION � {! DEPTH
REGISTRATION NO. ( s' LJ COUNTY MANHOLE REFERENCE UPP
NO. DESCRIPTION OF WORK FEE LOWE[2
HOUSE SEWER CONNECTING TO mil
PUBLIC SEWER @ $3.00 O
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONF�EECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. /'CIIIt9G P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TOP*
P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. /V 6 JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. �1
WORK TO HOUSE SEWER @ $1.00ALTERIR OR ABANDON
SEWEFe R DISPOSAL SYSTEM HOUSE @ $i 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Isl 0--el REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DES IBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE AL PROPERTY. BACKFILLS
SIGNATURE S CESSPOOLS e
OF PERMITTEE
®P ALIDATION ROBERT A.WOOD
CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER