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1 6A 642 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES , SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNG
JOHN A LANIBIE County Engineer 2- rrOi I)FAI 44j5-Sr
COLEMAN W JENKINS, Sup't of Building
YTFOR APPLICANT TO FILL IN5T
LEGAL I III
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DESCRIPTION LOT NO OWNER
MAIL
BLOCK � TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCE D BY
BUILDINGS BK PG
)t.dZ
CONTRACT - ripil, r+- t)
ADDRESS �� , CONNECTION DATA
CITY ' TEL NO STATION / DEPTH
N0 LICENSE .} fUPPE
LI LLA 55 MANHOLE RE REFERENCE
NO ` DESCRrPTION OF WORK FEE - TYPE OF CO TION LENGTH OOM
HOUSE SEWER CONNECTING TO Y R P L M L TOP L
PUBLIC SEWER C $ 5 00 _
SEPTI TANK, SEEPAGE PIT OR 30(
PC NO }
PITS AND/OR DRAINFIELD C $1 O 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO (�
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEa E.SEMENT RECORD IN5TR NO DATE O
WORK TO HOUSE SEWER C $ 3 00
REPAIR OR ARAN N HOUSE
SEWER OR DISPOSAL SYSTFM C $ 3 00
HWY OR ST WIDENINGLUW
d
E%TN ,CESSPOOL, MANHOLE @ $ 5 00 STATE ENCROACHMENT H
PERCOLATION TEST @ $ 5 OG PERMIT NO a
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 42e CONNECTION CHARGE FEE
IEHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMD CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW � APPROVALS DATE INSP ECTO,R S SIGNATURE
SIGNED THIS�L cA DAY OF • ,� i1 19�t�
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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED UIRED ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH I �M THE L AL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN HE A V ESCRIBE RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMITTEE - - _ SEEP PITS) ❑ CESSPO❑OLS 3/
V LIDATION /J1�
CK M O CASH 'J)�✓
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