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76A642D APPLICATION FOR PERMIT
6A842 �J
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
JOHN A. LAMBIE, County Engineer ADDRESS 9 y opt
WILLIAM A. JENSEN, Sup't of Bu>lchng
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS STS'cPr
,EGAL
DESCRIPTION LOT NO OWNER 9
/ MAIL !
BLOCK TRACT �V ADDRESS /
NO OF BLDGS . '
SIZE OF LOT 0 1f NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
C �-B-•K P G �s d/'
CONTRACTOR 'y(,..� �/G ey S 1 �' /_3 �2r�
ADDRESS ` O a-S �.�SS r CONNECTION DATA
CITY TEL NO ->y#rq r STATION _ DEPTH
• ❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO YCURB P L M L TO P L
PUBLIC SEWER C $5 00 a
SEPTIC TANK SEEPAGE PIT OR P C NO O
P
PITS AND/OR DRAINFIELD @ $10 00 CO IMO JOB NO
V
HOUSE SEWER CONNECTING TO TRUNK PER IT NO ^}RGAD PERMIT NO Q[
PRIVATE DISPOSAL SYSTEM @ $3 00
/ CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEX[NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3 00 V
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL,DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING '
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT 6'•
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 00
AUTHORIZATION TOTAL FEE " CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW R - APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF LGA/ 19�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORN
ADDRESS
SEPTIC TANK SEEP,PIT(S)
I HEREBY A KNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS [EE
SSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFSAL SYSTEMCALIFORNIA OR THAT I AM THE LEGAL OWNER OF, D INTEND TOLUG ANDRESIDE IN THE ABOVE ESC BED RESIDENTIAL PERTY SE SEW ERSIGNATURE CKFILL SEPTIC TANKSOF PERMITTEE EP.PIT(5) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
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