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DMSYON OF BURDINGG APPLICATION SAF YSEWER- SEAN GE DISPOSAL 1
D%-ftn n: o[ Coati Enuhie r
Co=ty of Los An"i" BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
m CASHATT D. GRIFFIN, HUr'r or BUILDING LOCALITY
FOR APPLICANT TO FLLL IN CROSS ST. •
LEGAL OWNER
LOT NO.
PAIL
BLOCK TRACT ADDRESS
NO, OF BLDG$. CITY /��,+ TEL. O.
SIZE OF LOT NOW ON LOT
USEOF
BUILDINGS DISTRICT N0. GROUP YAP
BUILDINGS
BK PO
CON
TRRCTOR
CO ON DATA
ADDRESS
STATION DEPTH
CITY TEL N0. �o.qMANHOLE HF ER EN CE UPPER
ATE
REGI9TRATIOX 0. ❑ COUNTY
No-. DESCRIPTION F FEE
HOUSE SEWER CONNECTING TO _ TYPE OF CONNECTION LENGTH FROM
.Y: CURB P.L. Y.L.TO P.L
PUBLIC SEWER 4@ S 9.80
SEPTIC TANK,SEEPAGEPIT OR
PITS AND/OR DRAINFIELD 0 $4.60
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
EXTN.,CFS3POOL,DRYWEL MANHOLE 2.00 CO. IMP.NO. JOB XO.
HOU$qq"ER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 40 1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER S 1:00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGIF FEE
OWNSE'S S 1 00
A=O$MZ.ATION AL nm REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRA WITH THE HEREIN MED CON- APPEOVAL$ _ DATE INSPE OR 3SIGNATURE
TRACTOR TO CONNECT THEE ABOVZ DESCRIBED EXISTING DWCL{,INB
TO THE P}1BLIC SEWER. XEW HOUSE SEWER X26'
SIGNED THIS OF 19� CONNECT ADDITIONAL
OWNER QR BUILDING OR WORK
OWNlais Ra -10
SEPTICTANK,SEEP,PIT(S)
ADDR AND/OR DRAINFIELD
I HEREBY ACKXQWLHDGE TMAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATr, LAWS REGULATING ALTM REPAIR,SEWER OR
PLUMPING AND SEWERS. SEWAGE DISPOSAL SYST Y
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCOMIJECT PLUG AND
LICENSED AS REO IRED BY Lpp9 ANGELES COUNTY XD STATE OF BANDON HOUSE SEWER
ALIFORNIA OR HAT I `THE L L OWNER TH ABOYE
CRIBED$Psl TY• ACXYPIT(Y6❑ILL CTANKS
CES SPQ0❑
31 Ll.+
D YI
JOHN A. LAMBIE COUNTY NGINEER VALIDA ROBERT A.WOOD, CHIEF PLaG. INSPECTOR
9R AW8 4,.5-0
2F7e!$°zo°4 APPLICATION FOR PERMIT
COUNTY OF LOS ANGEL S$ SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINNEEB
BUILDING AND SAFETY DrMION e ILDINo
Cal=J'�_+��.�.�w!_R`_� ++JEpvanCLA `SI Yb+++� LOCALITY
NEARE15T
FOR APPLICANT TO FELL IN `R°" RTLKOAL L
FDLOCRIrTIONLOT NO. OWNERbMAIL
CK TRACT ADDRESSNO. OF OLDGS.
OF LOT NOW ON LOT CfTY L. NO.
OF DISTR NO. GROUP MAP PROCESSED ryLDINGS SK O
CONTISACTOR
ADDRESS CTI02f DAT/�
CITE' HO, 3 STATION G"� '_D ETTH y....
/TAT[ MANHOLE REFEIIEIICE fw V�
REGI RATION NO. COUNTY
No. DESCRIPTION OF WORK FEt TYPE OF CONNECTION LENOTH FROM
HOUSCSEWKA CONNECTING TO Y. CU MIS
F.L. it.L TO P.L
PU PILIC PKWKIR $5.00
15 DTIC TANK,S FAO[P OR JOB NO.
1•ITif AHD/OR DRAINFIELD SIO.00 CO'.IM F.No. JOS NO. ^
HORSE 15EWER CONNECTING TO 17UNK PERMIT NO. ROAD PERIRFT NO. U
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT BAlt[n I LAALnKET RECQRD.INSTR.NO. 16ATZ
WORK TO HOUSC SEWER $3.00
OVERFLOW SEEPAGE FIT,DRAINFIKID
KXTM.,CESSPOOL,DRYWELL,MANHOLE 0 $15.00
AiA DO O HWY.OR ST.WIDEryINO
EEyy
SWR SYSTEM � 7.00 STAT[ENCROACHMENT -i
PERMIT NO. L
INDUSTRIAL
WAST[APPROVAL
OWNERS I FEB M s 2 00 rH
Ro
AUTHORIZATION I TOM FEE n�1 CONNECTION CHARGE FEE
.1 HAVE AT TH15DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMSU hSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED [x ISTING DW CLL Ino
TO THE PUBLIC SEW APPROVES DATE I NSPECTOR'S SIGNATURE
SIGNED TH 19 ( DAY OF.
OWNER oRNEW H000K SEWER
OWNER"AGENT CON N[CT AODI'PIONAL
■UILDING OR WORK
ADDRESS SEPTIC TANK.SELP,PIT(S)
I HEREBY ACKNOWL 0[ AT 1 HAVt READ THIr AFrLICATIOM AND/6R DRAINFIELD
AND STAT[ TRAT THE ABOVE I■ CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY 0RDINAN C[1 AND STATE LAWS REGULATING
FLU M1, AND 15EW ERI. LDi000NNKCT
❑ DRYWEll ❑
I HEREBY CERTIFY THAT I AM PROPERLY R[OIST[RED AND/ORPAI R.Snv[R OR
LICENSED AS ACQUIRED BY LOS ANGLES COUNTY AND STATE OFISPOSAL SYSTEM
CALI FO RKIA OR THAT I AM THE LEGAL OWNER OF, ,AND INTEND TOCT PLUG AICD
RESIDE IN, THE A D SED R QENTIAL RROPERTY. HOUSE SEWER■IONATURE Ie[PTIC TANKI ❑OF PERMITTEES) ❑ CEAMP06LB
ALM.0. N ROPSING ME A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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