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COUNTY OF LOS ANGEL SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION BUILDING 2
ADDRESS
JOHN A LAMBIE, County
Eag7aeer
C SATT D GAI£FIN, Supt of Build�aq. LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT N0� OWNER
BLOCK TRACT ;7;:piT MAIL
ADDRESS
NO OF B DGS
SIZE OF LOT NOW ON LOT CITY/' TEL NO �a
USE OF
DI DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS �.P/ BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY L NO f J . STATION � DEPTH
i S
[��TATE MANHOLE REFERENCE �� UPS
REGISTRATION NO / �3�^� ❑ COUNTY
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00
YPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00 I
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 p C NO /� d�C
HOUSE SEWER CONNECTING TO CO IMP NO JOB NO
PRIVATE DISPOSAL SYSTEM @ $1 00
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 0:5'0 REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE NAMED CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTItNG DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER , j�j� �J
SIGNED THIS_s QDAY OF ���� 19 YEW HOUSE SEWER Z' f�srd� SIAr/
OWNER OR y�ti '/G CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1HEREBY ACKNOWLEDGE THAT 1 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
1ICWER HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES UNTY AND STATE OF ABANDON HOUSES AND
CALIFORNIA OR THAT AM THE LEG 0 R OF THE ABOVE
DESCRIBED OR ROPERT BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS) ❑ CESSPOOLS
OF PERMITTE O
®' �ALROBERT A WOOD
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!!t 0 CASH SUPERVISING MECHANICAL ENGINEER
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9 0 0 DEC 6 1 0 a 5.0',0