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76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7iSST.
JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Supt of Building
FOR APPLICANT TO FILL IN 40
LEGAL
DESCRIPTION LOT NO. OWNER-
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. _
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP P E Y
BK PG
RCONTRACTOJ� M5
X:'
ADDRESS MVV CONNECTION DATA
CITY TEL. N t ® STATION DEPTH
b
MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ 'COUNTY LOWE
NO. DESCRIPT ON OF WORK IFFEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO rte, Y. CURB M.L.TO P.L. !o
PUBLIC SEWER @ $5.00 _
SEPTIC TANK,SEEPAGE PIT O R JOB NO. U
PITS AND/OR DRAINFIELD @ $70.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WnIYER EASCMENT RECORD. INSTR.NO. DATE p
WORK TO HOUSE SEWER @ $3.00 6SAPI
OVERFLOW SEEPAGE PIT,DRAINFIELD
EA
XTN.,C ESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00
• AUTHORIZATION TOTAL FEE 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
TO THE PUBLIC SEWER. APPROVALS ( DAT INSPECTORS/S IIiN�'TURE
SIGNED THIS DAY OF 19_ - IQ ,e O'•�J�f�V`"
OWNER OR NEW HOUSE SEWER �;
OWNERS AGENT_ / \
CONNECT ADDITIONAL
BUILDING OR WORK �-
ADDRESS
SEPTIC TAN K,.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 I
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 LL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABftDECR E$IDENTIAL PROPERT ABANDON HOUSE SEWER
SIGNATUREIOF PERMITTEE BACKFILL SEPTICTANKSac SEEP.PIT(S) ❑, CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
/ CASH
M.O. SUPERVISING MECHANICAL ENGINEER
I CK.