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�FJ&E-66 APPLICATION FOR PERMIT��''�` '`��`'� 5
&E-888 11.55
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
-t. JOHN A. LAMBIE,COUNTY ENGINEER ADDRESS ;
CASSATT D.GRIFFIN, SUPT OF BUILDING ';."`
LOCALITY ""t,�� f4 j`,k14 e (f"'/�fI'
FOR APPLICANT TO FILL IN CROSS ST. t L �> "^r!` l G5LEGAL
DESCRIPT LOT NO. OWNER. �,r � �r� , [' A.
BLOCK TyIE �'R'>�E !�' ADDRESSl/ {j'.,/1^�/ E,tf:�AC..f�� (r 4'.
NO.OF BLDGS. ""jr=°
SIZE OF LOT NOW ON LOT CITY ,Cjl if. („ 1 TEL. NO.,f
USE OF DISTRICT NO. GROUP MAP
BUILDINGS BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS r
STATION DEPTH
CITY TEL.NO. UPPER
MANHOLE REFERENCEr
❑ STATE COMM
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM -
f PUBLIC SEWER @ $.$+'�� Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
i
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ o0
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK,SEEP,PIT(S)
_ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —
WITHALL 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/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BYLOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P PERTY, BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) [ICESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION -_ ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
M.O. CASH
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