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6K8086.60 APPLICATION FOR PERAIT �-C-l�K��i...a.iL4/
>BA6g20 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER - -
BUILDING AND SAFETY DMSION BUILm NG
ADDRESS
IOHN A. LAMBIE, County Eaginoar
WILLIAM A. JENSEN, SuP't of Building LOCA LIT
•� - - � - -- � � NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. S S ��� OWNER s
BLOCK ` 1BTRACT I ' '� 'MAIL
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY EL. NO.
USE OF
BUILDINGS DISTRICT t 11 GROUP K MAP PG P CEBBED BY
N0.O, T
CONTRACTOR R �v , 0 Y ! I I �'�-��..
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION DEPTH
STATE MANHOLE RE FIERCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER CO $3.00 TYPE OF CONNE ON LENGT IfROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. M.L. Q P.L.
PITSAND/OR DRAINFIELD @ 83.00 \
OVERFLOW SEEPAGE PIT. GRAINFIELD
EXTN..CESSPOOL.DRYWE LL @ $2.00
HOUSE SEWER CONNECTING TO P,C.NO.
PRIVATE DISPOSAL SYSTEM @81.00 CO.IMP. NO.
0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMT NO. V
@
WORK TO HOUSE SEWER %1.00
AtTER-REPMR-BRABANDON HOUSE STATE ENCROACHMENT P7
SBW^c1YCR OISPOSA L SYSTEM @ SI.00 Z OHO PERMIT NO. O
INDUSTRIAL G
WASTE APPROVAL M
CHARGES b
OWNER'S PERMIT S 2 UO CONNECTION CHARGE FEE
AUTHORIZATION ITOTAL FEE 06 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 THISY OF T 1Sy NEW HOUSE SEWER
OWNER OR .CONNECT ADDITIONAL
/
OWNERS AGENT rBUILDING OR\YORK
ADDRESS d / SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT
E ECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWEL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER O
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I PROPERLY REGISTERED AND DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOSS ANGELES COUNTY AND STATE OF .ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDENTIAL OPERTY,, /�
SIGNATURE /J ' /.{ _//�_ SEEP.PIT(SI CESSPOOLS B
OF PERMITTEE G[. Pe/Q"R/✓ //61 A, '
®r VALIDATIOP;� ROBERT A. WOOD
CK. M.0. 'r u✓sHSUPERVISING MECHANICAL ENGINEER
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