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76A642D 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
WILLIAM A. JENSEN, Supt of Building G
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSB BT.
LEGAL oe
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT ` CITY TEL. NO.
USE OF
BUILDINGS DISTRICT IN GROUP MAP PROCESSED BY
—— ,� BK PG /
CONTRACTOR
?LO
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ADDRESS L ✓ I Q�fe CONNECTION DATA ��L•�C�L
CITY STATION DEPTH
�7. EL.
'0-STATE UPPER
MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM �.
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. C.
PUBLIC SEWER @ $5.00 O
P.C.NO. V
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. .108 NO.
PITS AND/OR DRAINFIELD @ $10.00
T K RMIT NO.
HOUSE SEWER CONNECTING TO N O
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR FIDAVIT wAIVER EASEMENT RECORD. fNSTR.NO, DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD'
EXTN.,CESSPOOL,DRYWELL,MANHOLE 0 $5.00. HWY.OR ST.WIDENING +tn
ALTER.REPAIR OR ABANDON HOUSE `
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
IOWNER's PERMIT $ 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBEDEXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED O ANGLES COUNTY AND TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 T LEGAL OW OF, D TEND TO
DISCONNECT PLUG AND
RESIDE IN, THE AS D 'RIBED RE IITIAL P OP TY. ABANDON HOUSE SEWER
SIGNATURE El
PERMITTEE / BACKFILL SEPTIC TANKS C�
SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATIONROBERT WOOD
K.
/�../,j SUPERVISING MECHANICAL ENGINEER
CM.O. CASH