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TsnsnzD AkICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
D PARTMENT OF COUNTY ENGINEER _
UILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDREss
LLIAM A. JENSEN, Sup't of Building
OC PUTT _
- - NEAREST
FO PPLICANT TO FILL IN `ROSS ST.
LEGAL
DESCRIPTION LOT OWNER
MAIL
BLOCK A NDO. ADDREss
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF pISTRICT NO. GROVP MAP PROLE �D BY
BUILDINGS
CONTRACTOR
ggqq J f o/\ L—K F
ADDRESS LLLJJJ WWW CONNECTION DATA
STATION DEPTH
CITY TEL. NO. `\
REGISTRATION NO. O COUTNTY MANHOLE REFERENCE ER
NO. DESCRIPTION OFWOR FEE TYPE OF CONNECCjj�10�!I LENGTH F M
HOUSE SEWER CONNECTING TO Y. CV RBI�T r/-P!L. M.LTOP.L X }a
JOB NO.
PUBLIC SEWER @ 85.00
SEPTIC TANK,SEEPAGE PIT OR P C NOO
PITS ANO/OR DRAIN FIELD SIO.00 CO.IMP. NO. U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ft0 D NO �Z
PRIVATE DISPOSAL SYSTEM @ $3.00 ✓ (N
CONNECT ADDITIONAL BLDG.OR �4 AFFIDAVIT Alv[R .SEMEN RECO STR.NO. DATE 0
WORK TO HOUSE SEWER @ 53.00 3 (I V
OVERFLOW SEEPAGE PIT,GRAINFIELD �!
EXTN..CE55POOL..Nl WELL.MANHOLE@ $5.00
AL TER.REPAI R OR ABANDON HOUSE WY. OR ST.WIDENING N
SEWER O DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
SP�J PERMIT NO,
T' INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED'CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING `.11
TO THE PUBLIC SE E APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAV OF 19 �] ��/ �/� . rN
OWNER OR 1I NEW HOU SE SEWER ...(fff ��� ';]_; -Y1-'TS-A,�i'.n�I
OW NERS AGENT
CONNECT ADDITIONAL �r
3 BUILDING OR WORK
ADDRESS ` ..
I HEREBY ACKNOWL DGE THAT I HAVE READ THIS APPLI ATION SEPTIC TANKS PIT 15)
ANO/OR GRAINFIELELD
AND STATE THAT THE ABOVE IE CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
CESSPOOL El DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER ORCE
LINSED AS REQUIRED UY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE ICDAi. .1yKIR OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE AS ESCRIBEO R 51 NT AL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑ J
OF PERMITTEE_ BACKFILL SEPTIC TANKS N
SEEP.PIT 15) ❑ CESSPOOLS �.
LIGATION
M.OCASH ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. .
IN
L"1 5 7 2�— JUL21 1 O D �1�0.0 0-
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