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DIVISION OF BUILDING ARID SAFETY SEWER—S EWAG E D O S POSH L
Deportment of County Engineer
County of Los Angeles ADILDIN DRESSG PA k. '7
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JOHN A. LAMBIE, COUNTY ENGINEER A� a
® CASSATT D. GRIFFIN, SUP'TOFBUILDINc- LOCALITY F. /v 4 (2 f
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NEAREST
FO& A PLICAN TOEOIL /vi R
q LEGALyS y OWNER
DESCRIP 1 N LO 0.
MAIL
BLOCK -TRACT - ADDRESSA IX
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NO. OF BLDGS. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
P, USE OF �, "Q,. tY 0. O�-•� t/ /y DISTRICT NO GROUP MAP
BUILDINGS r� r,
B� PG
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CONTRACTOR" '5r _E_
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o 17 CMHOVE AVE. CONNECTION DATA
ADDRESS
�II-DTY 1 LBELL6 PA. 1 5048 STATION
f - DEPTH
a CITY TEL. NO. MANHOLE REFERENCE UPPER
148bJ ❑ STATE
REGISTRATION NO. ❑ COUNTY
NO, DESCRIPTION OF WORK FEE ' TYPE OF ION LENGTH FROM
HOUS9S"EWER CONNECTING TO l•� 'Y. P•L. M.L.TO P.L. Jl
PUBLIC SEWER @ $3. 'C•
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDP.•C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. 10B NO.
HOUSE SEWER CONNECTING TO C
PRIVATE DISPOSAL SYSTEM @ $1.00 - TRUNK-PERMIT-NO. ROAD PERMIT NO,. >,J
CONNECT ADDITIONAL BLDG.OR � STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 r PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL j i
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROV G4
- CHARGES "
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00 •
AUTHORIZATION TOTAL FEE •' REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- APPROVALS DATE INSPECTOR`S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /
TO THE PUBLIC SEWER. - NEW HOUSE SEWER
SIGNED THISDAY OF UA Al 19� CONNECT ADDITIONAL
OWNER OR -
'BUILDING OR WORK
OWNERS AGENT
SEPTIC TANK,SEEP, PIT(S)
ADDRESS V, 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 AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ` DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
-
CALIFORNIA OR T T I AM H LEGAL OWNER 0 ^THE ABOVE
DESCRIBED RESIDE PRO RTY BACKFILL SEPTIC TANKS ��}
SIGNATURE SEEP. PIT(S) ❑ CESSPOOL
OF PERMITTEE /oR�`AC/f/tOGSF -
JOHN A. LAMBIE, Cou Ny(EN EER VALIDATION ROBERT A._WOOD,CHIEF PLBG. INSPECTOR
CK M. O. CASH -
L&2 2 6 9 27 1. 0 A 7.0 U
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