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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE ®9 S( OSA L
Deportment of County Engineer
County of Los Angeles BUILDING ° A gp
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 0.7A) /?° r
® CASSATT D. GRIFFIN, SUP'T OF BUILDING
- LOCALITY '
FOR APPLICANT TO FILL IN CROSS ST.LEGAL
,v.. DESCRIPTION LOT NO. 3J;� `^ /� �� ` OWNER /rL/lU
MAIL
' BLOCK - TRACT �p ADDRESS
NO.OF BLDGS. CITY ✓- TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT,NO. GROUP MAP
..� {✓ +GSL
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BK � PG
CONTRACTOR
ADDRESS' VN 5,4A rA AIV1�'�'A -y • CONNECTION DATA
�. CITY . TEL. NO. / 6. 7� / STATION �J v;, DEPTH
❑ STATE MANHOLE REFERENCE.Z .rS.K 15� LOWER\
^ REGISTRATION NO. // b ❑ COUNTY i 'S
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO y, TYPE OF G6N1�lECTION LENGTH FROM
- - Y- CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD C. NO. .
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $ 2.00 CO. IMP. NO, r A' JOB NO.
HOUSE SEWER CONNECTING TO °
PRIVATE DISPOSAL SYSTEM @ $1.00 _ _ $ TRUNK PERMIT NO. ROAD PERMIT NO.%���
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT ,
WORK TO HOUSE SEWER @ $1.00 PERMIT NO. -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL - -
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT g 1 00
REIMBURSEMENT FEE '
J AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE. INSPECTOWSSIGNATURE
;* TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING •^ ,�-� �
TO THE PUBLIC Sl ERR NEW HOUSE SEWER _
SIGNED THISc DAY 0 �/g�V 1J CONNECT ADDITIONAL
OWNER OR / _ BUILDING OR WORK
OWNERS AGENT_ SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
A 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. 9 SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 1 DISCONNECT PLUG ANDI
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPER Y. �, BACKFILL SEPTIC TANKS1:1
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS
OF PERMITTEE 07 rg
.JOHN A.'LAMBIE, COUNTY ENGINEERVALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. O. CASH -
0461 .6—Ln NOV26 4 4.50 , M.