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CE008- APPLICATION FOR PERMITcanoe-ane COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL �.
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION ADDRESSG
'
JOHN A. LAMBIE. C.0 ty Engineer
CASSATT D. GRIFFIN. Sup'l of Building LOCALITYJZ'�
NEAREST
FORAPPLICANTTO FILL IN cRDsssr.
LEGAL ?
DESCRIPTION LOT NO. A- OWNER'
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE I DI$iRICT N0. GROUP MAP PROCESSED BY
BUILD INGS � _/1 L'P� J � BK PG
CONTRACTOR G�
ADDRESS`�j' _ / CONNECTION DATA
• logCI �/�p�� � TEL./NOO.4Z .��4' STATION DEPTH
REGISTRATION N0. / (O %iLI COUNTY `'TATE MANHOLE REFERENCE UPPER
I NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR - ITT
TYPE OF COyf,WCTION LENGTH FROM
PITS AND/OR DRAINFIELD Q $3.00 °� Y. URB P.L. M.L.
TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM �@ $I.00 Co.IMP. ND. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER fW $1.00
ALTER, REPAIR O R ASYSTEM HOUSE $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
_ CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE QD REI MBURSEMENT FEE p¢
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-INAPPROVALS !/ DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLG
TO THE PUBLIC SEWER. 7
SIGNED THIS DAY OF IS_ F NEW HOUSE SEWER i-25-49
OWNER OR CO N NECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK.
SEPTIC'TANK,SEEP,PIT(S)
ADOBESAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT L-AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT] PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS
OF PERMITTE '
®a /VALIDATION ROBERT WOOD
A 1f:Kd SUPERVISING MECHANICAL ENGINEER
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