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APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D I S POSA L
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C=mty of Los �ea�j BUILDING r
JOHN A. LAMBIE, COUNTY ENOINI3HR ADDRESS
m CASSATT D. ORiFFIN, SUP rDr BUILDING LOCALITY Y
FOR APPLICANT TO FII.L IN CROSS ST
LEGALOWNER
DESCRIPTION LOT N0. E. 8
MAIL
BLOCK TRACT ADDRESS
��NN of BLDGS. CITY TEL. n0.
SIZE OF LO /��NOW ON OT
BUUIILDINGB DIMIgT N0. GROUP YAP
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
STATION DEPTH
CITY TEL. X0,
,��,rr MANHOLE RffEAENCE
Id STATE LOWER
REGISTRATION N0, ❑ COUNTY
No. DESCRI N F WORK FEB TYPE OF CONNECTION LENGTH MOM
HOUSE SEVE7t CONNECTING TO Y. CURB P.L. Y.L.TO P.L.
PUBLIC SEWER 1.110
SEPTIC TANK,SEEPAGE PR OR
PITS MD/OR DRAINFIELD Q S.DO
OVERFFLOW SEEPAGE PIT,DRAINFIE P. C. NO,
i
EXTN.,CESSPOOL,DRYWELL MANHOLE 2.00 Co. ITR. N0, JOB no.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM i 1.00 TRUNK PERMIT 0, ROAD PERMIT NO. J
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT 1
WORK TO HOUSE SEWER 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
INDUSTRIAL
SEWER OR DISPOSAL SY9TEY 1. 0
0
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PIAT i 1 00
AUTHORIZATION' TOTAL FEE R¢IreuRserENr FEE
I HAVE AT THIS DATE A CONTRACT 11TH THE HEREIN NAMED CON- $OVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEWER /
SIGNED THIS- AY OF 19 'CONNECT ADDITIONAL
OWNER OR 13UILDMQ OR WORK
OWNERS AGENT _ SEPTIC TANK,SEEP,PIT(9)
ADDR.0 MD/OR DRAINFIELD '
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION .�P00L❑ DRTWELL❑
MD STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL ltYMM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
ND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY MABANDON HOUSE SEWER
STATE OF DISCONNECT PLUG WEA
1
CALIFORNIA OR THAT AI THE
DESCRIBED RESIDEN ROPELEGAL OWNER E ABOVE
RTY. BACKFILL LEP"[IC TANKS[ISIGNATURE SEEP.PIT S) ❑ CESSPOOLS El
OF PERMITTEE
JOHN A LAME. Co ENOIN6QR VALIDATION ROBERT A.WOOD, CHIEF PLED. INSPECTOR
■.0. 'CAST
_T( 3 3 3 6 M21 ' 4 450 In