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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS Q l�-
�VILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
OR APPLICANT TO FILL IN CROSS T.
LEGAL
DESCRI PTION� LOT NO. �."r WNER
MAIL
LOCK TRAC .-Jf ` / ADDRESS JBY S `2 O. OF BLDGS. CITY \ TEL. NO.
SIZEv OW ON LO7USE OF DISTRICT NOJGROUP MAP PROC ED
BUILDINGS BK PG I'
CONTRACTOR
ADDRESS O CONNECTION DATA
CITY may,,. L. NO. ( I
STATE STATION[_ DEPTH / I
_
MANHOLE RE FERE NUPPER
C '-
REGISTRATION NO. •,,�� �'* -.�� J /ry s-- - �
NO. DESCRIPTIONP OF WORK FEE TYPE OF CONNECTION LE GTH F M,;/-
/
HOUSE SEWER CONNECTING TO Y. CURB P.L M.L.TO P.
PUBLIC SEWER @ $5.00 '
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
7'L'MNO / JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ,^,-.
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIYER EASEMENT RECORD. INSTR.NO, DATE F
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 1 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z o0
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
-IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT , ( C• f' CONNECT ADDITIONAL
a� BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT IHAVE READ THIS 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 [I DRYW ELL ❑
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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ' '�^
OF PERMITTEE '�'.r - - BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑.�
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
2 ? Oma' APR 13 1 v D 7.00-