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S&E-663 3-55 APPLICATION FOR PERMIT 1
S&E-6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I S POSA L
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS �7
® CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT O MAIL !! L
ADDRESS
F BLDG .
_SIZE OF LOT �Jy ��'l NOWOON LOTS / CITY TEL. NO.
USE OF
BUILDINGS � DISTRICT N0. GROUP MAP
BK PG
CONTRACTOR
CONTRACTOR "^ ,� , E -6, y
ADDRESS G / CONNECTION DATA
CITY � EL. NO. C �O {� STATION DEPTH
- � � ❑ STATE MANHOLE REFERENCE A-
REGISTRATION NO. LOWER(�
NO.� DESCRIPTION OF WORK FEE NNECTIO I
^� TYPE OF COLENGTH FROM
HOUSE SEWER CONNECTING TO @ $ 3.50 / Y. CUP.B P.L. M.L. TO P.L.
PUBLIC SEWER
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 __ J
CONNECT ADDITIONAL BLDG. OR �/'
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. (�
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR "-
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
PERMIT
OWNER'S s 1 00
AUTHORIZATION TOTAL FEE c REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE O THEA ABOOVEWDESCR BED EXIISTITH THE ING DWELLING APPROVALS DATE INSPECTORSSIGYA7URE
TO THE PUBLIC SEWER -
NEW HOUSE SEWER
SIGNED THIS DA 19� - 2
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
LEBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
G AND SEWERS. SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/CR
D AS REQUIRED BY LOS ANGE S COU TY AND TATE O DISCONNECT PLUG AND
NIA OR THAT 1 AM THE L A 0 R OF E AB E ABANDON HOUSE SEWER
ED RESID IAL PR RTY +• BACKFILL SEPTIC TANKSSEEP. PIT(S) ❑ CESSPOOLSREMITTEE
WILLIAM J.FO OUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
& 4930 DEC 4.5
CE808 ° APPLICATION FO PERMIT
76A642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F
ILDING
DRESSJOHN A. LAMBIE. County EngineerWILLIAM A. JENSEN, Sup't of Building CALITY f FOR APPLICANT TO FILL IN
NEAREST ST
LEGAL
DESCRIPTION LOT NO. f OWNER +Y f C. .� ,[/[ /C: rr{ 'mss
BLOCK TRACT , ` MAIL
'_ ADDRESS
NO.OF BLDGS.
SIZE OF LOT �' 1 /' -'` NOW ON LOT CITY TEL. NO. d
USE DI DISTRICT NO. ROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR
f'
ADDRESS CONNECTION DATA
I CITY / TEL.NO. STATION DEPTH
STATE MANHOLE REFERENC7E UPPER
REGISTRATION NO. B COUNTY r LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE ot CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00 y,
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00 0
HOUSE SEWER CONNECTING TOC.N0. U
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP.NO. JOB NO. i+
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. G.
WORK TO HOUSE SEWER @ SLOO r
ALTER,REPAIR-OR�ABANDON HOUSE •'+"'• STATE ENCROAC NT
SEWER OR DISPOS46,SYSTEM @ $1.00 PERMIT NO.
INDUSTWA L 00
WASTE APPROVAL
CHARGES H
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE IINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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
LDESCRIBED
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
OR THAT I AM THE LEGAL OWNER OF THE ABOVE
REST E;ITIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLSTTE.
Or VALIDATION_ ' ROBERT A. WOOD
CK. M.o, cAsx SUPERVISING MECHANICAL ENGINEER
.i f