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76A642D APPLICATION APLICATION F'OR PERMIT �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER ®� r
�L MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS N DISTRICT NO. GRO MAP PROCESSED BY
'BK P G
CONTRACTOR
ADDRESS p CONNECTION DATA �'ry
CITY /OOA. a TEL. NO. V � STATION . T,s DEPTH X
J
REGISTRATION NO. Lj STATE
L) COUNTY MANHOLE REFERENCE ��f-ry
j L� F UGR
NO. DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FOM /
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.LR.
PUBLIC SEWER @ $5.00d
SEPTIC TANK,SEEPAGE PIT ORCO.IMP. NO. JOB NO. O
� P.C.NO.
PITS AND/OR DRAINFIELD CSP $10.00 V
/'���HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. y
PRIVATE DISPOSAL SYSTEM @ $3.00 / IIX
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 ~
U
JVE'ERFLOW SEEPAGE PIT,DRAINFIELD {y1
ESSPOOL,DRYWELL,MANHOLE@ $5.00 R ABANDON HOUSEHWY.OR ST.WIDENING
OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
REIMBURSEMENT FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ /� ;
OWNER OR NEW HOUSE SEWER '
OWNERS AGENT_?.PO"�) CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINAN S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT AM PROPE LY R GISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSEDAS REQUIRED LOS ANGL COU TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 M THE LEGAL WNE OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB D SCRIBED RE IDE IA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILLS PTIC TANKS ❑
OF PERMIT T ❑
SEEP.PIT(S) ❑ CESSPOOLS
G
VALIDATION ROBERT A. WOOD
M.O. CASHSUPERVISING MECHANICAL ENGINEER
Lril,v 5 7 8 0 NOV 12 1 0 D 7.00-
`Ii
6A642 0-63 APPLICATION FOR PERMI `-�-
76A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION77
BUILDING /!'
JOHN A. LAMBIE, County Engineer ADDRESS 4Y
WILLIAM A. JENSEN, Sup't of Building
LOCALITY O
NEAREST
FOR APPLICANT TO FILL IN CRD55
LEGAL
DESCRIPTION LOT NO. � OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY ITEC. .NO.
3
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDING
CONTRALTO ,^O,� BK_ P�
ADDRESS \.l 46
CONNECTIOY^N DATA
vs
STATION
CITY TEL. NO. J(� DEPTH
U i
❑ STATE MANHOLE REFERENCE { / S,�„n UPPER
REGISTRATION NO. ry,yam-� ❑ COUNTY !�J / �t`JV 6
NO. DESCRIPTION OF WORK FEETYPE OF TION LENGT FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L. P.L, f
PUBLIC SEWER @ $5.00 57 DO y ///M_ P.C.
SEPTIC TANK,SEEPAGE PIT OR CO. IMP. NO. / �5C/ JO O
PITS ANDOR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. AD PE T NO. /� O
PRIVATE DISPOSAL SYSTEM @ $3.00 '(/
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVIII EAS..6N7 R COR INS R DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 FLN
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 53.00 STATE ENCROACHMEpe z
PERMIT NO.
INDUSTRIAL
WASTE APPROV L
OWNER/S PERMIT $ 2 00 CHAR ES
AUTHORIZATION TOTAL FEE O CONNECT ON CHA GE FE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DA�Y OF-
19_
OWNER OR NEW HOUSE SEW50/
OWNERS AGENT / , CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS_ SEPTIC TANK,SEEP,PIT(S)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I+�AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A YJESCRIBED R ENTI PR PERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATIONS-7.) ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LACO5 8,6 NOV 13 1 0 D 7.00- 14