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76A6420.� - APPLICATION FOR PERMIT
TBA 842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DMSION BUILDING v� / G / /V/7/3,
JOHN A, ]AMBLE. CounlY Engineer
ADDRESS
WILLIAM A. ]ENSEN. Supt of Building_ LOCALITY G�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. aita OWNER �(
BLOCK TRACT HAIL '-
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO,
USE OF
BUILDINGS A DISTRICT NO. GROUP BK MAP P CESSED BY
CONTRACTOR <G L=- PG
u
ADDRESS CONNECTION DATA
CITY L, TEL.NO. 2_ O �/�/L O STATION I ,DEPTH
REGISTRATION NO. (/ B COUNTY STATE MANX�ETE;ER I�N/CE Z� '!'/7/ [ 2 LOWER
NO. 1 DE5CRIPTION'OF YVUHK FEE 1 '
HOUSE SEWER CONNECTING TO e�
PUBLIC SEWER @ $1.00 .J 7�C ,CON C LENGTH FROM
P
SEPTIC
ANN.SEEPAGE PDT OR @ S11.00 Y. L. M.L.TO P.L. a L
OVERFLOW
IVITNF LCESSPOOLGORTWELRAINFIEPD @ S .00 ' d
HOUSE SEWER CONNECTING TO P.C.N0. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.INP.N0. JOB N0. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT X0. d'
WORK TO HOUSE SEWER 9 .00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT O
SEWER OR DISPOSAL SYSTEM @ 1.00 PERMIT NO. V
INDUSTRIAL W
d
WASTE APPROVAL h
CHARGES ?
OWNERS PERMIT f 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE D REIMBURSEMENT FEE
1 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. _ '-
f
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL / r
OWNERS AGENT f r; BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITIS) /
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELP
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OP CONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ,ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THAT A THE LEGAL OWNER OF THE ABOVE
WER
DESCRIBED RESIDENTIA P ERTY. BACKFILL SEP IC TANKS ❑
SIGNATURE /'L�/"J/ SEEP.PIT S CESSPOOLS
OF PERMITTE
VALIDATION
ROBERT A. WOOD
CK. U.0. WH SUPERVISING MECHANICAL ENGINEER
U 8795 D 7.00 N
Q :T
-E�
76A6420 APPLICATION FOR PERMIT
]GA G42
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y-
PORN A' LAMBIE, County Enggineer ADDRESS G /A
WILLIAM A. IENS54 SYp't of Huildivg LOCALITY
NEAREST71
FOR APPLICANT TO F l IN CROSS ST.
DESCRIGP ION LOT 170. OWNER / Q/
BLOCK TRACT MAIL
D ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE
BUILDINGS ' n � DISTRICT NO. GROUP YAP PR ESSED BY
�r
CONTRACTOR RK / PG
ADDRESS S r CONNECTION DATA
CITY TEL.N0. (Y(j STATION DEPTH
STATE MANHOLE REFERENCE i
REGISTRATION N0. d B COUNTY LOWER
EE
No. DESCRIPTIO O _
HOUSE SEWER CONNECTING TO ]
PUBLIC SEWER @ $4.00
Y
SEPTIC TANK.SEEPAGE PIT OR TTP FCO E LENGTH FROM
PITS AND/OR DRAINFIELD @ $4.00 . P.L. M.L.
TO P.L.
OVERFLOW SEEPAGE PIT.DRAIXFIELD l
EATN..CESSPOOL. DRTWELL @ S .00 y
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1100 CO.IMP. N0. JOB NO. U
CONNECT ADDITIONAL BLDG. R TRUNK PERMIT NO. ROAD PERMIT NO. l
WORK TO HOUSE SEWER / $I 0
SEW ER,REPASP00R SYN SHOUSE @ S 00 STATE ENCROACHMENT
PERMIT N0.
_ INDUSTRIAL w
WASTE APPROVAL N
OWNER'S
Z
O��rYYyYER�S PERMIT § .../ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE " 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 THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONALOWNERS AGENT �L BUILDING OR WO RK
ADDRESS SEPTIC TANK,SEEP.PIT(St /
AND/OR DRAINFIELD /
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL (] DRYWELL 13
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
SIGNATUE
DESCRIBED RESIDENT L OPERTY. SEEP.PS) C] CESSPOOLS
n
OF PERRMITTE
VALIDATION �c ROBERT A. WOOD
OL M.0. WH SUPERVISING MECHANICAL ENGINEER
2796Q� MAY1g 1 1 D 25.00 r=
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