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76A6A 642D APPLICATION FOR PERMIT
6
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER "
BUILDING AND,SAFETY DIVISION FNEAREST
JOHN A. LAMBIE, COUNTY ENGINEER r
COLEMAN W. JENKINS, SUPT OF BUILDING
OR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK - TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT f
Y TEL. NO
USE OF _ - R ICT NO. GROUP CLASS MAP PG PROCESSED Y
BUILDINGS � -
GONTRACTOR
ADDRESS VV CONNECTION ((DATA _
CITY D EL NO I ATION
',4
/
—DEPTH A
F V
STATE LIC NHOLE REFERENCE C UPPER
LICENSE NO GLASS ��J
I
NO •DESC IP ON OF WORK FEE TYPE OF C ON LENGTH FR M�ter,
HOUSE SEWER CONNECTING TO j _ CURB P L M L TO P L. (�
PUBLIC SEWER @ L/
SEPTIC TANK:SEEPAGE PIT OR P.0 NO.
PITS AND/OR DRAINFIELD SID 00 t
CO IMP,NO No
HOUSE SEWER CONNECTING TO "- TRUNK PERMIT NO ROAD PERMIT NO �J
PRIVATE DISPOSAL SYSTEM -S300 / d
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER -EASEMENT RECORD INSTR NO. DATE O
WORK TO HOUSE SEWER $3 00 V
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN.CESSPOOL DRYWELL MANHOLE $S 00 .HWY.OR ST WIDENING O
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT _ V
PERMIT NO uj
INDUSTRIAL
N
WASTE APPROVAL z
OWNERS PERMIT $1
n00�
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
1HAVE 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 INSj CTOR'S SIGNATURE
SIGNED THIS - DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT`
- CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK +
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THA I AM PROPERLY REG TERED AND/OR ALTER,REPAIR SEWER OR '
LICENSED AS REQUIRED B LOS ANGLES COUN AND 'STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A THE LEGAL OWNER F, AND INTEND TO DISCONNECT PLUG AND '
RESIDE IN, THE AB V SCRIBED RE TI P OPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMrrF[E- BACKFILL SEPTIC TANKS- ❑
EEP PIT(S) ❑ CESSPOOLS ❑ / �' z
V ATION JACK R.'ALL N
C K CASH SUPERVISING MECHANICAL ENGINEER
iALo O ry 0_ 7 JAN 2 5 1 0 o 1 0.0 0