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ASO42D -82 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDI'1G 3� 4�:
JOHN A. LAMBIE, County Engineer ADDWILLIAM A. JENSEN, Supt of Building LOCALITYNEAREFOR APPLICANT TO FII.L IN CRISSSIT.LEGAL !DESCRIPTION LOT NO. ,2f LC OWNERMAIL
BLOCK TRACT ADDRESS SIZE OF LOT �� 0 NOWOON LTS CITY TEL. NO.USE OF �, DISTRICT NO. GROUP MAP BUILDINGS I Off:N • BK PGCONTRACTORADDRESS
CITY 7_ T.L. NO. 7- -Z a Q STATION DEPTH
❑ STATE MANHOLE RE RENCE / UPPER
REGISTRATION NO. ❑ COUNTY „/ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CON TION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. V
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. 0
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. B NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERM O.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 y
OVERFLOW SEEPAGE PIT,DRAINFIELD L
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ABANDON HOUSE 1� HWY.OR T.WIDENING
DISPOSAL SYSTEM @ $3.00
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE �
(,•`C� CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGEN
CONNECT ADDITIONAL
ADDRESS Z BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I CAVE READ ArHIS 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 ❑ DRYWELL ❑
1HEREBY CERTIFY THAT 1 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 1 A THE LEGAL OWNER OF, AND IjiTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE SCR ENTI PROP Y. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE5 BACKFILL SEPTIC TANKS ❑ , _
SEEP.PIT(S) ❑ CESSPOOLI
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH