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76A642D APPLICATION FOR PERMIT
76A64COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING [-/�O) /'
JOHN A. LAMBIE. County EnginADDRESS J J 3J ( C/cM �
eer
WILLIAM A. JENSEN, Sup't of Building LOCALITY (/?v
NEAREST
_FORAP C 1T0 L IN CROSS ST. /¢tblJ
LEGA ` OWNER
DESCRIPTION LOT
�)
BLOCK TRACT MAIL
e. jf ADDRESS '
! NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT N�OJGROUPBK PG'MAP PROCESSED BY
CONTRACTOR 7 ��
ADDRESS - o CONNECTION DATA `
CITY ee TEL..NO.. Q JQ.2 STATION �� o DEPTH
,J117/ STATE MANHOLE REFERENCE I 4
REGISTRATION NO. COUNTY LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO Q V/i
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. I M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOW SEEPAGE PIT,DRAINFIELD -
_ EXTN..CESSPOOL.DRYWELL @ $2.0014
HOUSE SEWER CONNECTING TO P.C.NO J
L
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR 'TRUNK PERMIT NO. ROAD PERMIT NO. V
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR AL SYSTEM HOUSE @ $1 OO ,STATE ENCROACHMENT 94
PERMIT NO. O0
INDUSTRIAL V
WASTE APPROVAL a
CHARGES
OWNER'S PERMIT $ 2 x+900 CONNECTION CHARGE FEE
AUTHOMZAnON TOTAL FEE c) �Q REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING APPROVALS DATE INSPECT SIGt�ATUIjE
TO THE PUBLIC SE
SIGNED THIS DAY OF ANf! 1?y I9J2 NEW HOUSE SEWER
OWNER OR (/may CONNECT ADDITIONAL ✓
OWNERS AGENT / '/ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT 1 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 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 BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER ,e
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE1 '
DESCRIBED.RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ / S!may
SIGNATURE
SEEP.PIT(S) ❑ OL !✓I�- CESSPO
OF PERMITTEE
®eLI 0. ROERT A. WOOD
ctc. m..°, CASH SUPERVISING MECHANICAL. ENGINEER ,
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