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CE1308 8-SB APPLICATION FOR PERMI� �ISPOSAL
1
E808 6
COUNTY OF LOS ANGELES SEWER-SEWAGE
DEPARTMENT OF COUNTY ENGINEER le
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, CountF Engineer ■
CASSATT D. GRIFFIN, Supt of Building LOCALITY �^
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 171 'Or
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS. /J
SIZE OF LOT n� / NOW ON LOT It CITY TEL. NO.
USE
BUILDINGS c � DISTRICT NO. GRO MAP
PG ���pE�PROCE D BY
CONTRACTOR 'rjY 0
ADDRESS - o CONNECTION DATA
CITY �� TEL.NO./ '14TION 0 DEPTH
❑❑ STATE MANHOLE REFERENCE /
REGISTRATION N0. ❑ COUNTY A LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 —TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS 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 TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00 _
c ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOS L SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 571&V REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INS CTOR'S SIGNATURE
TO THE PUBLIC SEWER. , /
SIGNED THIS DAYOF�Z 19_ NEW HOUSE SEWER'
OWNER OR ���g-,/, 04/ CONNECT ADDITIONAL
OWNERS AGENT ✓ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
; SEWAGE DISPOSAL SYSTEM
i HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR - DISCONNECT CT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CTPLUGHOUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN IAL PROPERTY, BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP PITS) ❑ CESSPOOLS ❑
OF PERMITTEE119
®p `� VALIDATION ROBERT A. WOOD
K.
CM.0. CASH SUPERVISING MECHANICAL ENGINEER
_ll'l�o SIS
13 0 C
76AS420 P
CES08 8-69 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEW E DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY c
- - NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT FDISTRICT
TEL. NO.
USE OF R MAP PROCESSBUILDINGSPGCONTRACTORADDRESS CONNECTION D TA
CITY TEL.N0. II7C/e,® Q L�DEPTH
STATE MANHOLE REFERENCE
REGISTRATION N0. ❑❑ COUNTY LOWER
No. DESCRIPTION OF WOR F E
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX N..CESSPOOL. DRYWELL @ $2.00 / p,C.N0.
HOUSE SEWER CONNECTING TO CO.IMP. N0. r .3-S—JOB N0.
PRIVATE DISPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
�
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE JI 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.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I 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 TH T AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDEN 1 PROPERTY. .! s SEE PITS) ❑ CESSP OLS ❑
SIGNATURE
OF PERMITTE
®" VALIDATIO ROBERT A. WOOD
^i CK, M.O, H SUPERVISING MECHANICAL ENGINEER
�i uO 63 1 3SCa' 13 1 D 2 5 . C