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�E808 6-50 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
OHN A LAMBIE, Count En ADDRESS
eer a/
C TT D. GRIFFIN, Supt of Budchng LOCALITY trl
NEAREST i
FOR APPLICANT TO FRI IN CROSS Sr i.
LEGAL
DESCRIPTION LOT NO OWNER w �+ A
MAIL yy
BLOCK y lTRACT q/ / ADDRESS r J�-. ,./�.
SIZE OF LOT / 7 /1 / v NOW ON LOTS CITY o Sri C .� s2EL NO U (1 /
USE OF
BUILDINGS DISTRICT NO (GROUP i K MAP PG PROCESSED BY
CONTRACTOR Lynn L. Allen ;;z_i m - 6(, IAX.
ADDRESS 2157 X. IDurf e e CONNECTION DATA
CITY El Monte TEL NO G 1 B-4681 STATION g.0 DEPTH
167150 C-36 STATE MANHOLE REFERENCE ! U PER
REGISTRATION NO COUNTY 74 a OWER
No I DESCRIPTION OF WORK FEE
PUBLIC SSEWER CONNECTING TO @ $3 00 3 V V�
SEPTIC TANK SEEPAGE PIT OR Y TYPE OF UR ECTIONP L LMEL GT HPFLOM
o.
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO r P C NO
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG ORn TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00 0
0 '
ALTER
REPAIR
R
DISPOSAL R ABANDON SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 6 10 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 SEWE _ /!
SIGNED THIS DAY OF 19-WNEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREB ACKNOWLEDGE THAT HAVE REXID THIS APPLICATI
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP CESSPOOL [:1 DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS -SEWAGE DISPOSAL SYSTEM
1HEREBY 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 RESIDENTIAL WPERTY /' BACKFILL SEPTIC TANKS Cl
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
Or WWDATION 'ROBERT A WOOD
cK H o CASH I SUPERVISING MECHANICAL ENGINEER
Lf�
0 0 8 2 7 %`00 1 u;y 6 1 u h L 6.0 0
76A 642D t CE8' 10-71
'� APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7DDRESS
FOR APPLICANT TO FILL IN
r
LEGAL
DESCRIPTION LOT NO OWNEf
MAIL �J
BLOCK TRACT O �( ADDRESS
NO GS
SIZE OF LOT OW ON LOT CITY TEL NO
USE OF DIST ICT NO GROUP MAP PROCESSED BY
BUILDINGS �� BK /pP3
CONTRACTOR i �(�
r ECTIONN DAT
ADDRESS / 1
CITY TE NO `j STATION / DEPTH
STA LIC MANHOLE REFERENCE
LICENSE NO CLASS 4
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER @ $7 00
PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO
PITS AND/OR DRAINFIELD @ $1000 >_
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO LL
O
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMEXT RECORD INSTR NO DATE (�
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ SS 00 Q
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ S300 U
STATE ENCROACHMENT
W
PERMIT NO a
MANHOLE @ $7 00
INDUSTRIAL H
WASTE APPROVAL Z
OWNERS PERMIT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE ZOO
CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL nl
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(5)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA AM HE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A V CRIB 'S
SIGNATURE I D�EjNa TyI�A�L PROPERTY ABANDON HOUSE SEWER
�/✓vY //G-V BACKFILL SEPTIC TANKS ❑
OF PERMTTT SEEP PITS) ❑ ESSPOOLS ❑
VALIDATION DK' M D CASH
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