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CE808 2/70 APPLICATION FOR PERMIT
7AA 841D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENpINEER
BUILDING AND SAFETY DIVISION AoDI�i[saJFIRQCKISSIE
JOHN A. LAMSIE. COUNTY ENGINEER
COLEMAN W. JENKINS. SUPT. OR BUILDING LOCALITY T.�-1 LINCIRO■O ■T.
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USEOF DISTRICT NO. ■ROUP CLABS MAF
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QONTRACTOR R.IAJ.
ADDRESS A-9- CONNEnTOK DATA
CITY 'co cu TT TEL. NO. STATION ( DEPTH
STATE LIC LT�.. MANHOLE REFERENCE `J UFTER
LICENSE NO. .�11.�{� CLASS T
No. DESCRIPTION OF WORK - FEE TYPE of CONN[CTIo L[ w
HOUSE SEWER CONNECTING TO Y. Cu IRS
P.L M.L.T .L
PUBLIC SEWER
■ PT TANK.■ P E IT ORS, .i
ITS
AND/OR DRAINFIBLD 81 0.09 CO.IMP.NO.
HOUSIt SEWER CONNECTING TO TRUNK PERMIT NO. ROAD FEUr TT NO.
PRIVATE DISPOBAL SYBTEM 57.00 d
CONNECT ADDITIONAL■ G.OR AFFIDAVIT RECORD.IN■TR.Nq. DATI O
WORK TO HOUSE SEW" $3,00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOLDRYWELLMANHOLE 0 S5.00 0
ALTER. A A DO O HWY.OR ST.WIDENING `
SEWER OR DISPOSAL SYSTEM 43.00 STATE ENCROACHMENT IrVL,
PERMIT NO. a
INDUSTRIAL U)
WASTE APPROVAL Z
CHARGES
WNMS PERICT s OO
A OATLATION TOTAL FO-VCONNECTION CHARGE FEE _
EE
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON- RJEIM15URSKMKNT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED [XI/TING DWELLING
TO THE PUSLIC SEWAMOVAIS IN CTOR• IGNATUR[
SIGNED THIS 1c DAY OF. 4-A 4M 191-S
OWNER OR KEW HOUSE SEWER
OWNERS AGENT CONNECT ADDrTIONAL
ADDRESS •� •-� t W ILDINP OR WORK
SKPTICI HERESY ACKNOWL[DOE THAT I HAVE READ THIS APPLICATION AND/OR
DRATANK. FEEL PIT(S)
AND/OR DRAINFI[LD
AND STATE THAT THE ABq VE 16 CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS R116VLATING
PLU MBINO AND SEWERS. CESSPOOL ❑ DRYW[LL ❑
I
HER[RY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY kOt ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNEN
IA OR THAT I AM THE LEGAL OWNER OF, AND INTD TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANCON HOU■E■EWER
SIGNATURE v A}J�4-E c- SACKFILL■[Ff1C TANKS ❑
OF PCIRMIl l SEEP.PITS) LJ CESSPOOLS
ATION JACK R. ALLKN
CK. Y.O. CASH QUPERVISING MECHANICAL ENGINEER
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