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76A642 -61 APPLICATION FOR PERMT
76A 642D ��(�
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE. County Enggsneer ADDRESS i
WILLIAM A. JENSEN. Supt of Building LOCALITY
ST
EA REST --
FOR APPLICANT TO FII.L IN
CROSS ST. 1�
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT 4
ADDRESS e NO OF LDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF ! L. " � -
BUILDINGS
gg DISTRICT NO GROUP YAP PR SSED BY
CONTRACTOR/ ` G
ffl�-A d
ADDRESS CONNECTION DATA
N0.
STATION �1 DEPTH CITY �ECJ
STATE MANHOLE REFin
ERENCE UPPER
REGISTRATION NO. O COUNTY
Nn DESCRIPTION OF WORK FEE
! PUBLIC SEWER CONNECTING TO.---
PUBLIC
O."- @ $S 00
OU
SEPTIC TANK,SEEPAGE PIT OR TYPE OF-CO ON LENGTH PL.
PITS
PITS AND/OR DRAINFIELD @ SH 00 Y. P L. M L.TO .L.
OVERFLOW SEEPAGE PIT,DRAINFIELD �-
EXTN CESSPOOL DRYWELL '@S2 00 8.
HOUSE SEWER CONNECTING TOP C NO. O
PRIVATE DISPOSAL SYSTEM @ St 00 CO IMP NO JOB NO. V
CONNECT ADDITIONAL-BLDG.OR TRUNK PERMIT NO ROAD PERMIT NO
-WORK TO HOUSE-SEWERS"--- @ 41 00
SEWER OR DIISPOR-ABANDON
ALBYNTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL NJ
WASTE APPROVAL
CHARGES z
OWNER'S PERMIT s CONNECTION CHARGE FEE �}
AUTHORIZATION TOTAL FEE -' REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- p
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I P DATE INSPF�CT�'S;SI6NATURE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL 1 7 r
OWNERSAGENTI�t BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT l 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 SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON-HOUSE SEWER -
CALIFORNIA OR THAT 1 AM TH. LEGAL ER OF THE ABOVE
DESCRIBED RESID R R - BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS ❑ CESSPOOLS P.
OF PERMITTE
VALIDATION ROBERT A WOOD
CR. Y 0. CASY SUPERVISING MECHANICAL ENGINEER
1p.�;0 0 4 72 % APR 4 1 I ll 2 5 .0 0 t1=
-6,
76A642D APPLICATION FOR PERMIT
76A 642
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. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 'y ® f OWNER
DESCRIPTION LOT N0.
BLOCK TRACT MAIL r
ADDRESS
,NO.OF BLDGS.
SIZE OF LOT A NOW ON LOT CITY df6vL3& TEL NO
USE DISTRICT NO GBK ROUP MAP CESSED BY
BUILDINGS y...
CONTRACTOR �/f / 7
p4z 6,
ADDRESS 7,v .1� CONNECTION DATA
CITY Yd
L NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER .
REGISTRATION N0. 77 COUNTY
No I DESCRIPTIaN OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $S 00 O
TYPE CON C LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. C P. . M L.TO P.L. C
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00 n
HOUSE SEWER CONNECTING TOP C NO. O
PRIVATE DISPOSAL SYSTEM @ $t 00 CO IMP No, ! JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER $1 00
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT O
PERMIT NO V
W
` INDUSTRIAL a
WASTE APPROVAL to
CHARGES ?
OWNERS PERMIT S 2 0/0/1 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE !/'u REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S,SIGNATURE
To THE PUBLIC SEW
SIGNED THI LOP 12 NEW HOUSE SEWEROWNER OR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S) '
AND/OR DRAINFIELD
I 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 SYSTEM
I 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 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID IALP PE C SEEP FILL SPIT SEPTI 'ANKSCESSPOOS
SIGNATURE
OF PERMITTE
VALIDATION ROBE T A. WOOD
CL r 0. cAsx SUPERVISING MECHANICAL HNGINEER
7 -
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