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CE80810-63 APPLICATION FOR PERMIT
' COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS VT J / G /✓� �6 N
WILLIAM A. JENSEN, Sup't of Building
LOCALITY � O
NEAREST
FOR APPLICANT TO FILL IN CROSS ST` ,t
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO.. OF BLOGS. r1
SIZE OF LOT NOW ON LOT +.7 CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS [� BK PG J
C04
ONTRACTOR ( e e d-S � �j ✓ �"- � �
ADDRESS - ti p/-,,., ,�,, t�CONNECTION DATA
CITY Ji/L 0;�`f- TEL. NO. YQ STATION �/ - f/ DEPTH
[5—STATE MANHOLE REFFERENCE/` UPPER
REGISTRATION NO. ❑ COUNTY �,^>L, /�y/ J LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER @ $5.00
P.C. C
SEPTIC TANK,SEEPAGE PIT OR NO.
PITS AND/OR DRAINFIELD @ SIO.00 CO.IMP. NO. 3,. JOB NO. O
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 im
CONNECT ADDITIONAL BLDG.OR _ AFFIDAV� WAIVER EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 U � �;� V
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5,00HW- /
ALTER,REPAIR OR ABANDON HOUSE Y. O S ID ING !L /
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
OWNERS PERMIT
WASTE APPROVAL
HARGES
� 2 00
AUTHORIZATION.I TOTAL FEE /p O CONNECTION CHARD EE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR tiG1,l / NEW HOUSE SEWER
OWNERS AGENT/LiLW CONNECT ADDITIONAL f�
BUILDING OR WORK ��� ♦ ��r-y.`„�f'I/1,()
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINAN S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT AM PROP LY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
L
ED AS REQUIRED B LOS ANGU[ S C UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
RNIA OR THAT I A THE LEGA/OW ER OF, AND INTEND TO DISCONNECT PLUG AND
IN, THE ABOVE SCRIBED ESI NTIAL PROPERTY. ABANDON HOUSE SEWER
URE BACKFILL SEPTIC TANKSERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
9 9 3 U i-11 ii 0
d.� Cl`