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78A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING :NO :]JOHN A LAMBIE, County Engineer DDR655�WILLIAM A JENSEN Sup t of Building
LOCALITY _NEARESTFOR APPLICANT TO FILL IN `ROSS 5TLEGAL iDESCRIPTION LOT NOOWNERMAIL
BLOCK TRACT ADDRESS
NO OF SLDGSSIZE OF LOT NOW ON LOT CITY TEL
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS /yam/ �/ BK PG
CONTRACTOR �/�✓ / V Q
ADD RE S IIl�� CONNECTION DATA f
/ /
714 EL NO v' STATION , j. ` DEPTH
REGISTRATION NO Lf l/ ❑ STATE MANHOLE REFERENCE 7 �t r UPP
COUNTY Ri
NO DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO Y) CURB PL M L TO P p
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ 51000 CO IMP NO JOB NO ya V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
1.
PRIVATE DISPOSAL SYSTEM @ 3300
CONNECT ADDITIONAL BLDG OR AFFIDA7 WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 449 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES I D EXISTING DWELLING
TO THE PUBLIC SEW APPROVA S DATE INSPECTOR 5 SIGNATURE
5 N
SIGNED TI Al
DAY OF 19-
OWNER OR NEW HOUSE SEWER �� 1 / !� ��
OW NERS AGENT �'y
CONNECT ADDITIONAL /1
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANIVOR ALTER REPAIR SEWER OR
LICE NSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS POSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRED RESIDENTIA PROPERTY ABANDON HOUSE SEWER
SIGNATURE X BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) E] CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L � 9 8 8 6—�o JAN 18 I C D 7,0 0' y'