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- COUNTY OF LOS ANGELES • SEWER—S MAGE DISPOSAL -2
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
K ADDRESS
JOHN A. LAMBIE, CountF Engineer
CASSAI"C D. GRIFFIN, Supt of Building LOCALITY
NEAREST
ceoss ST.
FOR APPLICANT TO FILL IN
DESCRIPTION LOT N0.LEAL
v d OWNER G /�
BLOCK TRACTMAIL' J
a" ADDRESS
0 NO.OF
+�'
SIZE OF LOT NOW ON LOTS '2J CITY �Pr� �� `% NO.
USEOF
r LD NGS = DISTRICT NO. GROUP MAP PROCESS_ED BY
BK. P I
CONTRACTOR
ADDRESS CO NECTION DATA .
CITY. NO. � ION 4 DEPTH
REGISTRATION NO. `j.�C��
STATE
MANHOLE REFERENCE
No. DESCRIPTION OF WORK FEE
1- HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 O
r' TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.0019
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP..NO. 0 JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. [�
WORK TO HOUSE SEWER @ $1.00 `J
SEWER REPAIR DOSAABANDON L SYSTEM HOUSE @ $1 00 Y STATE ENCROACHMENT
�.. _ PERMIT NO.
ov—
J INDUSTRIAL -
WASTE APPROVAL
CHARGES
r
(` OVVNER'S PERMT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
HAVE AT 1TRACTOR TO CIS DATE A CONTRACT WITH THE HEREIN ONNECT THE ABOVE DESCRIBED EXISTING pDWELLING =- APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW
SIGNED THIS DAY OF NEW-HOUSE-SEWERx iq�'.! 1" ! r to s
OWNER OR CONNECT ADDITIONAL L
OWNERS AGENT .:. BUILDING OR WORK
ADDRESS � -SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD -
1 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 ^
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED AS REQUIRED LOS ANGELES COU AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT A THE LEGAL qVNER V THE ABOVE
DESCRIBED RESIDENjyL PR PERTY. BACKFILLSEPTICTANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS ❑ '
OF PERMITTE
®'. /,ALMATION ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
7BA642D . _ PER
Tceaoa a-sa s� PPUCAT ®N ® .. -
COUNTY OF LOS ANGELES '
SEWER—SEWAGE ®OSP®SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION an RE sG
JOHN A. LAMBIE; County Engineer J -
CASSATT D. GRIFFIN, Supt of Building LOCALITYNEAREST
CROSS
FOR APPLICANT TO FILL IN
LEAL
DESCRGPTION LOT NO. , OWNER -
BLOCKTRACT MAIL
�S ADDRESS
NO.OF BLDGS.
x SIZE OF LOT NOW ON LOT 3 CITY OLS% - / N0.
USE OF _
BUILDINGS _ DISTRICT N0. GROUP MAP PROCES 4 -BY
BK PG
CONTRACTOR
ADDRESS ,tog F CO VECTION DATA
/7
CITY �,j�//• L.NO. // � g p ION , DEPTH
�w MANHOLE REFERENCE
REGISTRATION NO. tCOUNTY �. '
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM.'.. /1
SEPTIC TANK,SEEPAGE PIT OR _ - Y. CURB P,)_. M.L.TO P.L. 0
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 a. RMI . ROAD PERMIT NO.
WORK TO HOUSE.SEWER .@ $1.00 TRUNK PERMIT N0P ®" <
ALTER;REPAIR OR ABANDON HOUSE 4, STATE ENCROACHMENT -
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
w INDUSTRIAL
,'. WASTE APPROVAL -'
CHARGES
OWNERS PERMIT $ 1 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL.FEE REIMBURSEMENT.FEE
I HAVE AT THIS DATE-A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE"DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER ^
SIGNED THIS DAY OF ����� ✓I9�� NEW HOUSE SEWER 7l®
OWNER OR - / CONNECT ADDITIONAL +' 9
OWNERS AGENT aal BUILDING OR WORK
ADDRESS `-IY 'e
SEPTIC TANK SEEP.
SEEP,PIT(S)
?,
I HEREBY ACKNOWLEDGE THAT 1. HAVE READ THISAPPLICATION AND/OR DRAIN
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES .AND 'STATE LAWS REGULATING s'
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED ASREQUIRED BY LOS ANGELES CO "- AND-STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT l THE LEGA WNER F THE ABOVE — sl
DESCRIBED RESIDENT! RO ERTY.- �', BACKFILL SEPTIC TANKS ❑ '•� _�
SIGNATURE S EP.PITEl CESSPOOL !!�
OF PERMITTE
®F LIDATION ROBERT A. WOOD
CIL Et.0. CASH SUPERVISING MECHANICAL ENGINEER