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76A642D APPLICATION FOR PER IT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
LDING �� o
JOHN A. LAMBIE, County Engineer RESS
WILLIAM A. JENSEN, Sup't of Building
AL.TY
FOR APPLICANT O FILL IN SS 5T
LEGAL '
DESCRIPTION LOT N OWNER
`' MAIL '
BLOCK TRACT v ADDRESS
NO OF BLDGS
SIZE OF LOT DD NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO GROUP X, MAP PROCESSED BY
CONTRALTO I
a� aP�
ADDRESS �� CONNECTION DATA �.
/ STATION DEPTH `7
CITY 2� EL NO ,.�
STATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY 7,_5 t ( LOWER +
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FR M
HOUSE SEWER CONNECTING TO Y. CURB P.L. M L.TO P ` C-
PUBLIC SEWER @ 35 0011-3 ^ CL
O
(� P C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO IMP. NO. JOB NO.
PITS AN./OR DRAINFIELD � SIO 00 U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. �
PRIVATE DISPOSAL SYSTEM @ $3.00 C((yyy ^ '
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIYEN EASEMENT RECORD INSTR NO. DATE 0
WORK TO HOUSE SEWER @ 53 00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5 00
ALTER,REPAIR OR ABANDON HOUSE
HWY OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 1 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH 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 OF 19_ +a
OWNER OR ••716 1 �VE A''��F
NEW HOUSE SEWER
OWNERS AGENT --
CONNECT ADDITIONAL J
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT i HAVE 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
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/,,OR ALTER. REPAIR,SEWER OR
LICEN5ED AS REQUIRED BY LOS ANGLES COUNTY AND STATEIOF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB VE DESCRIBED RESIDENTIA PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS C3OF PERMITTEE SEEP,PITS) ❑ CESSPOOLS ❑
/VALIDATION ROBERT A. WOOD
CK M.0. CASH SUPERVISING MECHANICAL ENGINEER
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