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76A64 2D APPLICATION FOR PERMIT
6A64 �J
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBLE Couniy Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building l
LOCAL TY Gee/
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST ! e.I.e, r42Vc�� r
LEGAL l �� C
DESCRIPTION LOT NO f6L�` OWNER -Y' C
MAIL
BLOCK TRACT ! / I ate' ADDRESS �z,'7 .LJ PO�P c,J� S-4
NO OF BLDGS — r
SIZE OF LOT 7.J h y V NOW ON LOT CITY d TEL NO VC/J
USE OFI
,rr DISTRCT NO GROUP MAP ZC CESSED BY
BUILDINGS �j t� BK PG
CONTRACTOR ), &
'
ADDRESS CONNECTION DATA
/
CITY ? T L NO_2 STATION DEPTH
ATE MANHOLE REFERENCE y ((
REGISTRATION NO COUNTY LOWER
NO DESCRIPTIOW OF WORK FEE TYPE OF CONNECTION LENGTH ROM y ar
HOUSE SEWER CONNECTING TO Y CURB PL M L TO P L `
PUBLIC SEWER @ 55 00 �
SEPTIC TANK SEEPAGE PIT OR `/ e PC NO 0
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
N
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT O "� V
PRIVATE DISPOSAL SYSTEM @ $3 00 Im
CONNECT ADDITIONAL BLDG OR AFFIDAVIT iv[ eAse MENT RECORD INSTR N DATE
WORK TO HOUSE SEWER @ $300 0
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 {�
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM] @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC EWE DATE INSPECTOR S SIGNATURE
S
SIGNED THIS DAY O 19�'ac, ,I n
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAV 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 O
PLUMBING AND SENERS CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS 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 ABOVE DESCRIBED E IDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE Z ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
Ao0908Z1_03 MAR 31 1 u D 7.00— w
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