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76A 6421D - CE808 - 9/73 APPLICAT N FOR P MIT
' COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER /
BUILDING AND SAFETY DIVISION nDDRelSS
LOCALITY
AMIIIIIIIIIIIIIII NEAREST
11 FOR APPLICANT TO FILL IN GROSS ST a-
LEGAL / `
DESCRIPTION LOT NO OWNER /
MAIL
BLOCK TRACT ' ADDRESS
SIZE OF LOT NOWOON LOTS CITY TEL NO
USE OF
BUIL DISTRICTNO GROUP MAP PROCESSED BY
l� BK P"
CONTRACTOR ? 10
ADDRESSC/ CONNECTION DATA
CITY NO STATION DEPTH
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STATE LIC UPPER
LICENSE NO / GLASS G—" ANHOLE REFERENCE
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L
PUBLIC SEWER 0 $7 00
SEPTIC TANK SEEPAGE PIT OR C NO
J
PITS AND/OR DRAINFIELD @ 51000
CO IMP N �� OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO
PRIVATE DISPOSAL SYSTEM � $300 ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIY[I1 [Ai[M[MT RECORD NS R NO DATE
WORK TO HOUSE SEWER $300
OVERFLOW SEEPAGE PIT DRAINFIELD O
EXTN CESSPOOL DRYWELL $500 V
ALTER REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT 0
PERMIT NO
MANHOLE (~j
$7 00 LV
INDUSTRIAL
WASTE APPROVAL Z
OWNER S PERMIT s CHARGES
��� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
ITHAVE AT THIS DATE A CONTRACT WIH 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 DAY Al 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT M
CONNECT ADDITIONAL n '
ADDRESS BUILDING OR WORK V `
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY D STATE OF SEWAGE DISPOSAL SYSTEM
CA LIFC,RNIA OR AT 1 AM THE LEGAL OWNER OF A D INTEND TO DISCONNECT PLUG AND
RESIDE IN TH ABOVE DESCRIBED IDEN7IA P PERTY
ABANDON HOUSE SEWER
SIOF APP EQM ���'Ei BACKFILL SEPTIC TANKS Cl
SEEP PIT S) ❑ CESSPOOLS �-
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6808565
16A 642 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TU
ILDING —+
JOIIN A 1 ANiR11 C ounty I ngmr er DDRESSC01 FNIA\IN JF NKINS Sup t of BuildingOCAL TY
EAREST
FOR APPLI NT TOLIN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT �f ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL N
USE OF
BUILDINGS DISTRICT NO GROUP MAP PG PROCESSED BY
CONTRACTOR
ADDRESS J ——, CONNECTION DATA
/3 STATION �J /( L/ DEPTH /
CITY �71 TEL NO ! C�-J 02, `•J
LICENSE / LICENSE / PPER
NO CLASS MANHOLE REFE RENCE
LOWER
NO rESCRIPPfION OF WORK FEE TYPE OFC CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER C $ 5 00
PTI TANK EE AGE PIT OR PC NO
CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD C $10 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO - V
PRIVATE DISPOSAL SYSTEM C $ 3 00 /
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER C $ 3 00 0
R A R ABAND N HOUSE V
SEWER OR DISPOSAL SYSTFM C $ 3 00 l!J
UVERFLOW SEEPAGE PIT UHAINIILLU HWY ORST WIDENING d
EXTN CESSPOOL MANI OLE @ $ 5 00 N
STATE ENCROACHMENT z
PERCOLATION TEST C $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON REIMBURSEMENT FEE
TRACTOR TO COV NECT 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
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(5)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ,r
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ 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 JEST ENTIAL PR OPERT A
ABANDON HOUSE SEWER �y
SIGNATURE
OF PERMITTEE /� BACKFILL SEPTIC TANKS ❑ }� v
/- V
SEEP PITS) ❑ CESSPOOLS ❑
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