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,78A642D COUNTY-OF LOS ANGELES
SEWER,=SEWAGE DI;SPO AL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION ,Bu1LADDRDESS-I T CSL
•
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, SuP"t of Building LOCALITY
_ 'NEAREST
FOR_APPLICANT TO FILL IN CROSS ST.
LEGAL' r /J /"'t �-- / OWNER _ 0 Y� 1 !5 � -
DESCRIPTION LOT N0.' ��S G-( � d�¢� /
BLOCK TRACT ]� MAIL • '
a'CJ ADDRESS
NO OF BLDGS. `
SIZE OF LOT NOW ON LOT CITY TEL•N0,
USE OF DISTRICT N0. GROUP ,_ MAP P OCESSED BY J
BUILDINGS BK
PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO. y — 'STATION ,.�) ,� DEPTH
y STATE MANHOLE R F RENCE - UPPER
REGISTRATION NO. zi'- _ COUNTY !OWER
NO DESCRIPTION OF WORK' FEE
HOUSE SEWER CONNECTING'TO -
PUBLIC SEWER" @ $3 00 TYPE OF CONNECTI N LENGTH FROM-
SEPTIC TANK,SEEPAGE PIT OR �Y. CURB P.L.' M.L.TO P.L.
ITS ANDIOR DRAINFIELD @ S3 00 ,
'OVERFLOW SEEPAGE PIT, DRAINFIELD v
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C NO.'
CO IMP. NO.43 S JOB NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 N
CONNECT ADDITIONAL BLDG OR 'TRUNK PERMIT NO. ROAD PERMIT NO. k O
WORK TO HOUSE SEWER @ $1 00 0
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT - Pq
SEWER OR DISPOSAL SYSTEM @ $1 00 'PERMIT NO - p ,
INDUSTRIAL U-
-WASTE APPROVAL µ1M,
CHARGES ul
OWNERS ,} PERMIT 3 2• 00 CONNECTION CHARGE FEE ,
AUTHORIZATION ".T
' OTAL FEE Q� REIMBURSEMENT FEE,
I HAVE AT THIS PATE A CONTRACT WITH THE HEREIN NAMED CON- `
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INS P CTOR'S SIGNATURE
TO THE PUBLIC SEWER. _
SIGNED THIS _ DAY4F 19= NEW HOUSE SEWER 1
OWNER OR .� /�-� CONNECT ADDITIONAL-
OWNERS AGENT V BUILDING OR WORK - - - - -
ADDRESS SEPTIC TANK,SEEP,PITS) j
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 Cl
WITH ALLg
ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR-
PLUMBINGRS SEWAGE DISPOSAL SYSTEM -
1 HEREBTHAT I AM 0 ERLY R ISTERED AND/OR
LICENSEDED BY LOSES COU TYATE OF DISCONNECT-PLUG ANDCALIFOR T 1 AM ' LEG L CE ABOVE ABANDON HOUSE SEWERDESCRI 1A1 PROP SECPFILL PIT(SEPOCCESSP00❑LS ❑
SIGNA
OF FT 7
17
®pVALIDATION ROBERT A. WOOD
M.Q. c�sH_ SUPERVISING MECHANICAL'ENGINEER, ;
�:. ' 8 38 5.0.O,
5�5 y a L' l e, IV,
tc(, s 1' 6r- W� i'yp' rev 24650, INSERT,
® gF
E6086.60 APPLI ATION FOR\ PER�� I - '• .;•
78A842D COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL.
'DEPARTMENT OF COUNTY ENGINEER'
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS Y
JOHN A. LAMBIE, Coun4Y Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY a
NEAREST
FOR APPI1 T- TO FILL CROSS ST _ B
LEGAL a �'✓� �5 � . -
DESCRIPTION LOT NO. T ,OWNER'.
BLOCK TRACTl MAIL L
C� ADDRESS +
NO OF BLDGS. 4
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
DISTRICT NO. GROUP MAP P OCESSED BY
BK PG
BUILDINGS -
CONTRACTOR 6 V �'"�• V Q4_ti1�
ADDRESSON TION DATA
4 CITY TEL.NO/1]6 04!2_7-V- STATION a /_/-&& O DEPTH
/� ❑ STATE MANHOLE F RENCE / UPPER
REGISTRATION NO. 7 '/ ❑ COUNTY •� LOWER'
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO /-
PUBLIC SEWER Co) $3 00 TYPE OF CONNECTION LENGTH FROM .
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.'
PITS AND/OR DRAINFIELD @ $3 00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 -
�3 .
HOUSE SEWER CONNECTING TO Q�'
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP N0. JOB NO �
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO.l O
.WORK TO HOUSE SEWER @ $1 00 U -
ALTER,REPAIR O R ABANDO SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT P4
/ PERMIT NO. p
INDUSTRIAL F"
_ .WASTE APPROVAL W
CHARGES rn
OWNER'SPERMIT CONNECTION CHARGE FEE -
AUTHORIZATION TOTAL FEE u p REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABO EDATE AT DESCRIBED EXIISTINGWITH THE HEREINAMED DWELLING ' APPROVALS- DATE INSPE TOR'SSIGNATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF_ 19- NEW HOUSE SEWER
OWNER OR Q CONNECT ADDITIONAL '
OWNERS AGENT - BUILDING OR WORK - - - - -
ADDRESS SEPTIC TANK,SEEP.PIT(S) -
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THA HAVE•READ' THIS APPLICATIONS
AND STATE THAT THE ABOVE ORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ i-WITH ALL COUNTY ORDINA E AND STATE LAWS REGULATING pLTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY TH 1 AM PROPERLY'REGISTE ED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUI ED Y OS ANGELES COUNTY-A STATE OF ABANDON HOUSE SEWER -•
CALIFORNIA OR TH T THE LEGAL OWNER 0 THE ABOVE -
CRIBED RESIDE IA PERTY. 6 BACKFILL SEPTIC TANKS ❑ _
LS�IGNATURE SEEP.PIT(S ❑ CESSPOOLS ❑
PERMITTE
( +/(zftm
®p VAIMATIO ROBERT A. WOOD
.CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER