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764421) APPLI ATIOIV FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION MBADDRESS% r
OHN A LAIE County Engin
ILLL4M A JENSEN Supt of Building )LOCALITY % ---
NEAREST
FOR APPLIC4NT TO FILL IN CROSS Sr
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT 1 t^ MAIL
J ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE
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CITY S G TEL N ¢ ATION S DEPTH _
i7 v 2 �2 ❑ STATE MANHOLE REFERENCE
REGISTRATION NO �G ❑ COUNTY LOWER
No I DESCRIPTION OF WORK FEE n
/ HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 UCOIMP
F CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR CURB P L 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 JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR PAIRO R ABANDON YSHOUSE @ $I 00 STATE ENCROACHMENT 03
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CON
TRACTORA TO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT WITH THE IINGAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS AY OF' 19_ NEW HOUSE SEWER fYo .9
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HER Y RTIFY THAT I AM PROPERLY GISTERED AND/OR DISCONNECT PLUG AND
LICEN D S REQUIRED BY LOS ANG LES C NTY AND STATE OF ABANDON HOUSE SEWER
CAL 1 OR THAT I AM THE AL .ER OF THE ABOVE
D R RESIDENTIAL PROPERT BACKFILL SEPTIC TANKS C]G U SE P PIT(S CESSPO S
01, VALIDATION-., ROBERT A WOOD
CK E7 0 ` CASH,," SUPERVISING MECHANICAL ENGINEER
-Y :0 OCT 4 1 r D 5 ,
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CE8M 6,
76A64A642D APPLICATION FIRERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A, LAMBIE County Engin ADDRESS
WILLIAM A JENSEN Supt of Bin)Lq LOCALITY w
NEAREST
FOR APP CANT TO FILL c OSS ST
LEGALOWNER
DESCRIPTION LOT NO
BLOCK TACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT 2 CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSE Y
70BK P6 y�
CONTACTOR `"J1
ADDRESS ^y 7 CONNECTION DATA
CITY .s TEL -�� DEPTH S
REGISTRATION NO J B SfATE COUNTY MANHOLE REFERENCE ,
/ LOWE
No DESCRIPTIO OF FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK
PITS AND/ORD AENFGELDT OR @ 33 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD d
EXTN CESSPOOL DRYWELL @ S2 00
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ $t 00 CO IMP NO1!5�16JOB NO U
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO/5 O Ix
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PERMIT NO U
LU
INDUSTRIAL 4
WASTE APPROVAL Z
CHARGES
OWAR S PERIIRI'T CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 0-0 REIMBURSEMENT FEE
CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGA CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER � sn�
SIGNED THISY 0 19_ NEW HOUSE SEWER
OWNER 6J � 1 CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR NORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT t 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 SYSTE
1 HEREBY CERTIFY T A AM PROPERLY R ERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIR S ANGELES CO AND ST TE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH A THE LEGAL 0 NER OF TL
ABOVE
DESCRIBED RESIDE 1 OPERTT BACKFILL SEPTIC TANKS ❑
SIGNATURE S55P PIT(S) CESSP OLS
OF PERMITTE
111
0
ALROBER
IL Y oT�4 WOOD
CL usx SUPERVISING MECHANICAL SNGi1NEER
LPI 3 4 566 "o OCT 4 1 1 c 2500 «