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70A6421)
5&E•663II-SS APPLICATION
F PERMIT
DIVISION OF BUILDING AND SAFETY . SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING-
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /� MAIL OWNER e
DESCRIPTION LOT NO. 7-
BLOCK TRACT ADDRESS
O. OF BLDGS. CITY ^ EL. NO.
SIZE OF LOT W ON LOT
USE OF DISTRICT N1 OUP MAP
BUILDINGS
BK PG
CONTRACTOR jrY,lJ�t/-�, �--�'"`�"� M
L COMiECTION 'DATA
I ADDRESS
CITY TEL. N0.
STATION �" S D. DEPTH
' '
MANHOLE REFERENCE _
❑ STATE LOWER
REGISTRATION NO. ❑ COUNTY I
r
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION - LENGTH F
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 • CO. IMP. NO.: -� 7 77 1013 NO.
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR `•;, STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
�. SEWER OR DISPOSAL SYSTEM @ $1.00 „ WASTE APPROVAL
x - - CHARGES
CONNECTION CHARGE FEE .
OWNER'S PERMIT 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON- APPROVALS DATE INSP•ECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW _{� CON NNEW HOUSE SEWER "' P
SIGNED THIS ��^f DAY F 19' '
. -- �. .E CT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT 'P SEPTIC TANK,SEEP, PIT(S) >
ADDRESS (...- AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 BY LOS ANGELES COUNTY AND STATE'OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEGAL OWNER OF HE ABOVE -
DESCRIBED RESIDENTI OPE BACKFILL SEPTIC TANKS E-1
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE c
JOHN A. LAMBIE, COUNTY ENGINEER VALID AT R BERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N. 0. CASH
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