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CEOB B a 89 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ^
ADDRESS A
JOHN A LAMBIE County Engmeer
CASSATT D GRIFFIN Supt of Building LOCALITY G
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL ) 1� �iL N b U
DESCRIPTION LOT NO I OWNER
BLOCK TRACTI/ MAIL
ADDRESS
NO OFBLDGS
SIZE OF LOTL/0 NOW ON LOT CITY TEL NO
USE OF CT NO GROUP MAP D BY
BUILDINGS { S DISTRID �I BK PG P CE SE
CONTRACTOR �I c �✓ d
ADDRESS
rd. Ili Ap tvvA 1>4 CONNECTION DATA
CITE B (/ �/�} TEL NO y Z STATION DEPTH
ATE REGISTRATION NO 4 / ❑ COUNTY MANHOLE REFERENCE
LOWER
No DESCRIP ION OF WORK FEE
HOUSE SEWER CONNECTING TO O•t�
PUBLIC SEWER @ $3 00 TOF CONNECTION--, LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y 1pf CURB 4PL M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
O v
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 , U
0q0_. CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 6 v REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH
T NAMED
TRACTOR TO CONNECT THE ABOVE ESCRED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWE /
SIGNED THIS AY OF_ 19" NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
�,
1 HEREBY ACKNO LEDGE THAT I HAVE READ IS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND GREE 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 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
DESCRIBED RESID NTIAZPRORTY^ BACKFILL SEPTIC TANKS ❑
SIGNATURE l`W�, SEEP PITS ❑ CESSPOOLS
OF PERMITTE
®" VALIDATIOIY/---) ROBERT A WOOD
CK m 0 e/CASH /-- SUPERVISING MECHANICAL ENGINEER
'.,o rJ 5 5 �41r� 3 1 0 D 6 C O r
0107d-e-11-7�