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76A642D APPLICATION FOR �MIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL;,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /�y
ADDRESS (0 GME
JOHN A. LAMBIE. County Engineer `f i
WILLIAM A. JENSEN, Sup't o4 Building LOCALITY Lac
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. r
LEGAL OWNER �V O
DESCRIPTION LOT N0.
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS. IF
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF T N0. GROUP MAP P OCESSED BY
BUILDIN S !!PENT
BK PGCONTRACTOR / _. -ADDRESS CONNECCITY TEL.N ON DEPTH
OLE REFERENCE .UPPER
REGISTRATION NO. LOWER
NO. DESCRIPTION WOR FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00YPE OF CONNECTION LENGTH FROM
SEPTIC PITS AND/OR DRAENFGELDT OR @ $3.00CURB P. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELDEXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 P. N JOB NO.CONNECT ADDITIONAL BLDG.OR PERMIT N0. ROADP T N0. VWORK TO HOUSE SEWER @ $1.00SEWERALTER• REPAIR OR OR DISPOSAL SYSTDON EM HOUSE @ $100 ENCROACHMENT pq
PERMIT NO. M
INDUSTRIALU
WASTE APPROVAL--f""-
CHARGES ta
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED-EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL
A
OWNERS AGENT BUILDING OR WORK
ADDRESS - SEPTIC TANK,SEEP.PIT S• _ -
AND/OR DRAINFIELD
I HEREBY ACK LEDGE THAT 1 HAVE READ THIS APPLICATION - -
AND STATE THA HE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL CO Y ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBIN N SEWERS. SEWAGE DISPOSAL SYSTEM
I HERE ERTIFY THAT I AM P ERLY G RED AND/OR DISCONNECT PLUG AND
LICENSE EQUIRED BY LOS A ES N D STATE OF ABANDON HOUSE SEWER -
CALIFO 1 THAT 1 AM THE AL E ABOVE
DESCR 1 T ERT f BACKFILL SEPTIC TANKS ❑
SIGN R - SEEP.PIT(S) ❑ CESSPOOLS ❑
OF ERMITTEE
OF VALIDATIOI�Y� ROBERT WOOD
CK. 1.0. CAsx / SUPERVISING MECHANICAL ENGINEER.
4 .0) 0 Ir
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