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S&E663
APPLICATION FOR PERMIT 1
BDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engmeer t�
County of Los Angeles BU'
DI
LNG
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS E 6 CT 1J
® CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY
- i FOR APPLICANT TO FILL IN CROSS s
LEGL
DESCRIPTION LOT NO OWNER r�,
MAIL
BLOCK TRACT � L` ADDRE
NO OF BLDGS CITY TEL NO rJ C �� ��
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NOGROMAP
BUILDINGS •P�-� UP I � �P�
CONTRACTO � Cyl�
CONNECTION DATA
ADDRESS
STATION / r 0 DEPTH
CITY �` TEL NO
MANHOLE REFERENCE C PPER
❑ STATE 1 eU
REGISTRATION NO
No DESCRIPTION OF WORK FEE
TYPE OF CONNECTION_� LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L '7
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO L 2—!qEXTN ,CESSPOOL,DRYWELL,MANHOLE @ $ 2 00 CO IMP NO T
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO `
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT g 1 00
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INS ECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING J h
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY 19 CONNECT ADDITIONAL v
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOW EDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM.
1 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 THAT I AM T LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PR T BACKFILL SEPTIC TANKS❑
SEEP PIT(S) [ICESSPOOLS❑
SIGNATURE
OF PERMITT
JOHN A LAMBIE COUNT ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK EI O CASH
LACQ9 1 2 9 L M'i 11- 4 4 .5 0 '�