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76A 6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING }
LOCALITY /o `i
OR APPLICANT TO FILL IN NEARESTcRosS ST. ►/� C/�fj�
(PRINT OR TYPE ONLY) L►
LEGAL . )�
DESCRIPTION LOT NO. y Ot j ,F V r` llo T d,Q OWNER
1 3 /4/3-- MAIL
BLOCK TRACT � ADDRESS '7-
SIZE OF LOT 74
7
NOWOON LOTS I CITY TEL. NO. �'� J"( [� 2-/Q
USE OF DISTRICTNO. BK GRO CLASS MAP PG PROCESSED BY
BUILDINGS
_S J
CONTRACTOR ��o
ADDRESS ✓✓✓ CONNECTION DATA or
CITU TEL. NO.
STATION DEPTH
STATE LIG MANHOLE REFERENCE / UPPER
LICENSE NO. CLASS q
NO. DESCRIPTION OF WORK FEE TYPE OF CONN CT LENGTH F M ` ()
HOUSE SEWER CONNECTING TO � Y. CURB P.L. M.L.TO P `/l
PUBLIC SEWER
P.C.NO
SEPTIC TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO..
PITS AND/OR DRAINFIELD $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER -EASEM[NT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00 OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE HWY. O
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT V
PERMIT NO. 4y
CL
INDUSTRIAL
N
WASTE APPROVAL
OWNERS PERMIT s 00 CHARGES
AUTHORIZATION 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 INSPE R'S SI A URE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
P
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SE TIC TANK.SEEP,PIT(5)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING n
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL u
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT IAM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE 1 ���/xJ� G
OF PERMITTEE --^=--�\ ✓ BACKFILL SEPTI T KCESSS
SEEP.PITS) - POOLS ❑
VALIDATI JACK R ALLEN
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
L Lo 7 9 I. ;S NUS 7 10 D 1 .o Q