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CE�Il0811-57 APPLICATION FOR PERMIT 1
1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /p / 1L
JOHN A. LAMBIE, County Engineer ADDRESS .L srlM�
CASSAIT D. GRIFFIN, Supt of Building LOCALITY
AL FOR APPLICANT TO FILL IN _ Al-
CROSS ST. 1-`eoe�j I/J?l�jN
DESCGRIPTION LOT N0. - OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS J'f DISTRICT NO. GROUP MAP
CONTRACTOR BK PG
E i
ADDRESS �+L,/�ci° CONNE TION DATA
CITY/ . r+ TEL.N0 .1 STATION / 'z v DEPTH
OZ �j ❑ STATE MANHOLE REFERENCE
REGISTRATION NO. J2 ( ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO Sf�
PUBLIC SEWER @ $3.50 TYPE OF CONNECTIOLENGTH FROM c� '
SEPTIC TANK,SEEPAGE PIT OR Y. CURB /P.6, ) M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR —�
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I 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 OF 1 9 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR,SEWER OR
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OW ER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P RTY, BACKFILL SEPTIC TANKS❑
SIGNATURE j SEEP.PIT(S) ❑ CESSPOOLS Cl
OF PERMITT
®r VALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
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