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6AB42 0-63 APPLICATION FOR PERM,
76A642D
CO NTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPART ENT OF COUNTY ENGINEER
BUILD NG AND SAFETY DIVISION BUILDING
JOH A. LAMBIE, County Engineer ADDRESS (J� ✓
WILLI M A. JENSEN, Supt of Building
LOCALITY {•':!_. --_.
NEAREST
FOR PLICANT TO FILL IN CRD56 5T. -
LEGAL
DESCRIPTIONT LOT Nt'. QJj -- OWNER
MAIL r
1✓ O �Q J
� q ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP BK PG MAP PROC ED BY
A,�-��. J
' - 3
CONTRACTOR ' ,�.d•-t �� (/V�'�L.L
ADDRESS ^� CONNECTION DATA d
STATION _ �• DEPTH
CITY TEL. NO. (/
t ❑ STATE MANHOLE REFERENCE PPER
REGISTRATION NO. ❑ COUNTY r ,.
NO, j DESCRIPTION OF WORK FEE TYPE OF CONNECT ON L GTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L TO P.L. iy r a
PUBLIC SEWER $5.00
SEPTIC TANK,SEEPAGE PIT OR 01:) P.C.NO. O
PITS AND/OR RAINFIELD $
10.00 r�IIC1 P. NO. .JOB NO.
DU
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. r�-- JY
PRIVATE DISPOSAL SYSTEM IN $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE F.
WORK TO HOUSE SEWER @ E3.00 U
OVERFLOW SEEPAGE PIT.DRAINFIELD LU
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 d
WIDENING N
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E 2 00
AUTHORIZATION TOTAL FEE d� CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED XISTING DWELLING
TO THE PUBLIC SEWER. y� JJ APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY O l�1 19G�
OWNER OR ,,I`"3 'E _I.y �.� t- NEW HOUSE SEWER
OWNERS AGENT ` ✓
_ CONNECT ADDITIONAL
,I '+^ •.^ f / BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE ES ED RESIDE.TIAL PROPERTY.
ABANDON HOUSE SEWER
SIGNATURE - BACKFILL SEPTIC TANKS ❑ D
OF PERMITTEE _ --. SEEP.PIT(S) ❑ CESSPOOLS 04 /../,
VALIDATIO,Ai"--,�, ROBERT WOOD
/��!) SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAUO 1 2 3 1,� APR 13 2 D 7.0 0
D
8 E-663 11.33
APPLICATION FOR PERMIT 1
8&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY C�
FOR APPLICANT TO FILL IN CROSS ST.
LEGALOWNER
DESCRIPTION LOT N0. t
L MAIL ��
BLOCK T CT' .,�. ADDRESS
LDGS. CITY TEL. NO.
S E OF LOT NOW 010
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTO
ADDRESS CONNECTION DATA
CITYTEL. N0. r< STATION DEPTH
Q�Q v CCC//J
MANHOLE REFERENCE UPPER
❑ STATE LOWER
REGISTRATION NO.
No. DESCRIPTION OF WORK FEE
TYPE OF CO CTION LENGTH OM
HOUSE SEWER CONNECTING TO Y. CURINI. P.L. M.L.Jr P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP. N0, JOB NO.
i EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
i HOUSE SEWER CONNECTING TO
i PRIVATE DISPOSAL SYSTEM @ $1.00 ��'C TRUNK PERMIT NO. R-6,11) PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHME
i
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROV
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE L►
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ APPROVALS DATE INSPEC R'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 BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S) ) f
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING ANDSE WERS
SEWAGE DISPOSAL SYSTEM _
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED REST ENT L P PER Y. BACKFILL SEPTIC TANKS❑
SIGNATURE _SEEP. PIT(S) LlCESSPOOLS[IOF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIO ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.O. CASH
�, 2 3 8 Jf;N 3 0 1 A 5.0 0