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76A642D APPLICATION FOR PERMIT
76A6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING j
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY - r
NEAREST
FOR APPLICANT TO FILL IN cRoss sr.
LEGAL )
DESCRIPTION LOT NO. Rot OWNER 71
4^ MAIL
BLOCK T CT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS � BK PG
CONTRACTOR
ADDRESS _C4ON/N,ECTI N DATA
CITY TEL. NO.+ ` STATION 7 7' DEPTH
I. STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. '.,./ COUNTY
NO. 1 DESCRIPTION OF WORK FEE TYPE OFC ON LENGTH F
HOUSE SEWER CONNECTING TO �Q�/� Y. CURB P.L. M.L.
TO
PUBLIC SEWER ® $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. O.
PITS AND/OR DRAINFIELD 510.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT WAIVII IA5911I11T RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD ~
EXT N„CESS POOL,D RYWELL,MANHOLE 53.00 V
HWY.OR ST.WIDENING UJ
ALTER,REPAIR OR ABANDON HOUSE a
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT U)
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 21 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED XI T NG DWELLING 'S SIGNATURE
APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL ` f
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THI S'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 El DRYWELL ❑
I HEREBY 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
LR
ALIFORNIA OR THAT THE LEGAL OWNER OF, AND INTEND,TO DISCONNECT PLUG AND
ESIDE IN, THE ABO SCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
IGNATURE CKFI L SEPTIC TANKS ❑
OF PERMITTEE '1^ fit' J1,�
r15p"S) ❑ CESSPOOLS ❑
DAT ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
uitso 1 6 3 7-0 fAY 17 1 0 D 7.0 0