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' Ci8082as, APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING;="
ADDRESS-_ `••x
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL -"
DESCRIPTION LOT NO. OWNER -
BLOCK TRACT MAIL
ADDRESS
NO,OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO. ROUP MAP PROCESSED BY
BK I;Z ( PG ..
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00
HOUSE SEWER CONNECTING TO P. C. N0,
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE 'i STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ S.1-i00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK a SEPTIC TANK, SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
I 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 ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I 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 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SEEP. PIT(S) ❑ CESSPOOLS ❑
SIGNATURE
OF PERMITTEE
1110
ill ®PVALI DATION
ROBERT A.WOOD
CK. U.0. CASH SUPERVISING MECHANICAL ENGINEER