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CE808 8.5lr APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 3 �7
ADDRESS G- C�
JOHN A. LAMBIE, County Encineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR 4PFLlfANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. ? OWNER
BLOCK TRACT - / MAIL
cr ADDRESS
NO.OF BLDGS. `
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF D
BUILDIN S G>!iCL�C.. 7� DISTRICT N0. GROUP MAP P ESSED BY
BK PG
CONTRACTOR -
ADDRESS •y CONNECTION DATA
CITY CTEL.N0. 1/ STATION DEPTH
REGISTRATION NO. / 7 COUNTY MANHOLE REFERE E UPPER
ST
LOWER
NO. DESCRIPTION OF WORK FEE —
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE 0 CO N CTI f H FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 _CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMITNO. AD PE
WORK TO HOUSE SEWER @ $1.00IL
•
ALTER,REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
_WASTE APPROVAL
CHARGES
OVMER'.S PERMIT $ 1 Z OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS—DAY 19_ NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
_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
1 HEREBY CERTIFY AT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIR BY LOS ANGELES CO TY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA S T 1 AM THE GAL�R OF THE ABOVE BACKFILL SEPTIC TANKS Cl
DESCRIBED RESID L PROPERTY. SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
OF — VALIDATION/—) ROBERT A. WOOD
CK. Y.O. CASH / SUPERVISING MECHANICAL ENGINEER
1 0 2 �.;,i 23 3.0 0
it
D
S&E-685 11-55 APPLICATION FOR PERMIT 1
8&E-8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING % ,.
BUILDINGS
JOHN A. LAMBIE, COUNTY ENGINEER DP _LOCALITY rADDRESS
® CASSATT . GRIFFIN. SUPT OF BUILDING �i .-t�4 � � �
_ FOR APPLICANT TO FILL IN - CROSSS T. t:.L d' G 2 C'
LEGAL �J
DESCRIPTION LOT NO. �!J '�'�' ��1.1 IO Z OWNER LZ . C
BLOCK TRACT � yyV 0'e ADDRESS I
NO.OF BLDGS. � 'I
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF �, '� DISTRICT NO. GROUP MAP
_
,� BK PG
CONTRACTOR �. i' 10
S
CONNECTION DATA
ADDRESS
STATION .f"�j ��j� DEPTH
CITY '` {s TEL. NO.�/��{/ �/�/�% MANHOLE REFERENCE U PER
STATE _ LOWER
REGISTRATION NO. Zlot"' �5-;7 ❑ COUNTY `
No. DESCRIPTION OF WORK FEW
TYPE OF CONNEON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50 —
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ` P. C. N0.
i
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. ( JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 _TRUNK PERMIT NO. ROAD PERMIT NO. {•'
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAME __ APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR T / ji:^• BUILDING OR WORK
OWNERS AGENT' AA SEPTIC TANK,SEEP,PIT(S)
ADDRES , '�� / l- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
LWITH
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
ING AND SEWERS. SEWAGE DISPOSAL SYSTEMEREBY CERTIFY THAT I AM PROPERLY REGI D AND/OR DISCONNECT PLUG AND
SED AS REQUIRED BY LOS ANGELE OU AND STATE OF ABANDON HOUSE SEWERORNIA OR THAT I THE LEG W R OF THE ABOVE
IBED RESIDENTIA PERTY. �� BACKFILL SEPTIC TANKS❑TURESEEP.PITS) ❑ CESSPOOLSERMITTE l
JOHN A. LAMBIE, COU Y,ENGINEERVk
LIDATIO /) ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
1 1 6 0 2 BRo.JUN .5 4 A4.5 O to
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