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C808 . APPLICATION FOR PERMIT
I eoe ., COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 5 I b .'.view- .
JOHN A. LAMBIE, County Engineer
CASSAIT D. GRIFFIN, Sup't of Building LOCALITYNEAREST
FOR APPLICANT TO FILL IN
CROSS T.
+� B ,
LEGAL OWNER l-~F ywA..
DESCRIPTION LOT NO.. /
MAIL
BLOCK TRACT ADDRESS IQl -{
NO.OF BLDGS. �+• r�
SIZE OF LOT .S X $O NOW ON LOT CITY T.v ,+,.. TEL. 10.
USE OF
BUILDINGS �+'-- DISTRICT N0. GROUP MAP y PR ESSED
BK PG7j1
/ r
CONTRACTOR /
ADDRESS ,y„ :� fk .. CONNECTION DATA
CITYTEL.N0. �)� H (� � STATION DEPTH Ilyy
e Q t'
$ STATE MANHOLE RE RENCE
REGISTRATION NO. � ) ❑ COUNTY f��
DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO O�
PUBLIC SEWER @ $3.00 1) TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD nZE
/v
EXTN..CESSPOOL. DRYWELL @ $2.00 `•'
HOUSE SEWER CONNECTING TO P.C.NO. res
PRIVATE DISPOSAL SYSTEM @ $1.00 .C.Ar-F#tP:"N0. 4f1B..". _5 J
CONNECT ADDITIONAL BLDG.OR TRUNK PERM N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00 •
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMEN
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUST
WASTE�APPROVAL
CHARGES
OWNERS PERMT $ 2 0061
c
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- '
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATFJ INSPECTOR'S S GN TUR
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR a/� CONNECT ADDITIONAL
OWNERS AGENT !Y vv BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
L
ESCRIBED RESI,DENTIA ROP�RITY• '7 BACKFILL SEPTIC TANKS ❑
IGNATURE `M r` wa �/ SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTED -i,� -,A.-.^
Or ALIDATION ROBERT A. WOOD
0.-
M.o, cum SUPERVISING MECHANICAL ENGINEER