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76A6A 642D APPLICATION FOR PERMIT'
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAR
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JOHN A. LAMBIE. COUNTY ENGINEER [�
COLEMAN W. JENKINS, SUPT. OF BUILDING � -
R APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
LEGAL 7 OWNER �C'".h�
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESSL/'` �4���
SIZE OF LOT f /� /��N`/O,/W OON LOBS(1 CITY �4MOo/��" /�E L. NO. -�Y�✓' �.a-�C/
13 USE
NGS ,�/ �G �i�"(iQO --Ie/Al �j'� DISTRICT N0. •.G./RROO-UP CLASS MAP PROCESSED BY
CONTRACTOR �,4�1 * �/ � el; w �` J-- � , 3 I,
ADDRESS,:Ugg lVa, S-' 4gr., / CONNECTION DATA
CITY � dJ.f� T.L. NO. ��7"3 / STATION �'� �� 7 DEPTH
UPPER
LTC ENSE NO.-1? 6&1Ae ATE / CIA ss SGP MANHOLE REFERENCE �e4 7 LOWS
NO. DESCRIPTION OF WORK FEE TYPE OF CON TION LENGTH FROM 2v
r HOUSE SEWER CONNECTING TO Y. R P.L. M.L.TO P.L.
/ PUBLIC SEWER @ $5.00 // P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. ®S� JOB NO.
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. '.Z
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT I RECORD.INSTR. NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00 HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE O
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO. Lu
INDUSTRIAL
h
WASTE APPROVAL
CHARGES
TTfOy��nN'E�/Rp'rS� PERMIT s _ 00
AU 1HORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEEg� A�,4��_�+ �+y APPROVALS D TE INSP TOR'S 5 G TURE
SIGNED THIS-�J 6Ja-DAY OF �- /7 19 Cs
OWNER OR NEW HOUSE SEWER {�
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. .CESSPOOL, ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DESCJD RESJ.p E OOPRY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS El �,
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS/❑
ALIDATION JACK R. ALLEN
`W SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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