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CE808 10-02 //� �3
7GA642D APPLICATION FOR PERNII
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDING .�.
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. J-ENSEN, Sup't of Building
LOCALITY C.
NEAREST
FOR APPLICANT TO FILL IN `RDS. ST e
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK �• TRACT ,'1Z ADDRESS
NO OF SLOGS. e�
SIZE OF LOT NOW ON LOT CITY / � TEL NO.
USE OF J'
BUILDINGS ?7e-v-( ll.,/,7 `LD/ISTRICT NO. GROUP MAP
��P PROCESSED BY
CONTRACTOR /V-(i/i .��/^IfCf ff'J I�Q . y 1 �� BKS 7�G
'ADDRESS %3tg f�-�/yam �7,p. CO�N'�NE///C...TION DATA
` CITY `Y&//"�QA!- TESL N0..J�j��J � ^�/� STATION / x 9 DEPTH
REGISTRATION NO J�/y' I>�STATE MANHOLE REFERENCE CJ / UPPER_,
❑ COUNTY
NO DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION LENGTH t OM f �-
/ HOUSE SEWER SEWER CONNECTING TO $5 00 -�p� CL
Y• CURB P L. M.L TO .L. J
PUBLIC
SEPTIC TANK,SEEPAGE PIT OR ( (•' 1 P.C.NO O
CO.IMP. NO ,,�i'.IOB NO
PIT.AND/OR DRAINFIELD � $1000 �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ^I O
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEM EASEMENT RECORD.INSTR NO DATE W
WORK TO HOUSE SEWER $300 _ d
OVERFLOW SEEPAGE PIT.DRAINFIELD to
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY OR ST.WIDENING Z
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
I WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE 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_ Q�� T� _ � .
OWNER OR - [ABANDON
W HOUSE SEWER VI-} !� !-r- /
1 I
OWNERS AGENT
NNECT ADDITIONAL
.. _ ILDING OR WORK
ADDRESS
PTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIOND/OR DRAINFIELD
'AND'STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS SSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TOCONNECT PLUG AND -
RESIDE IN, THE ABO ESCRIBED TIALPROPE RTY. HOUSE SEWER
SIGNATURECKFILL SEPTIC.TANKSOF PERMITTEE P,PIT(S) ❑ CESSPOOLS ❑
OVALIDATION ROBERT A. WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
LAC0 4 1 7 1% AN 7 1 0_ D 7.00-