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DIVISION OF BUILDING AND SAFETY SEY9E R—SEWA0 E DBS OSA L
Department of County Engineer ,..... M.:,,
County of Los Angeles BUILDING /r 1/1qe
JOHN A. LAMBIE, COUNTY ENGINEER - ADDRESS 6
® CASSATT D. GRIFFIN, SUPT of BUILDING •y LOCALITY •�yy�• �� '
NEAREST
FOR APPLICANT TO FII IN 1 CROSS ST. A
LEGAL I .•Z 7 —z' -
DESCRIPTION' LOT NO. - 0 11 OWNER -
BLOCK TRACT MAIL
//_ �/ ADDRESS
Y./� /X I ��.DI OF BLDGS. ` CITY TEL. NO.
SIZE OF LO7 OW ON LOT
USE OF ��c - DISTRICT NO. GROUP_ - MAP
BUILDINGS ,
J BK PG
CONTRACTOR ( - 0 ^,
ADDRESSZ- - �f. 7�CONNECTION DATA - -
�.
STATION
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e k
CITY / j(D,, `�C TEL. NO. �. 7 � Vd-3 _
DEPTH
'; MANHOLE REFERENCEtT� _ER -
REGISTRATION NO. /LA / �./ ❑ COUNTY a' LOWER
NO. DESCRIPTION OF WORK f FEE
HOUSE SEWER CONNECTING TOTYPE OF CTION LENGTH FROM -2-0 0
P.L. M.L.TO P.L.
Y. CURB"
.PUBLIC SEWER' @ $3.50 �-A
SEPTIC TANK,SEEPAGE PIT OR - -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO. .
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. iy'--Z> I JOB NO.
HOUSE SEWER CONNECTING TO �Q
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. O
CONNECT ADDITIONAL BLDG.ORSTATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 C) PERMIT NO, _
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 40p1
AUTHORIZATIONTOTAL FEE ` REIMBURSEMENT FEE
Uv APPROVALS DATE INSPECTOR'S SIGNATURE..
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEWER
SIGNED THIS DAY OF 19CONNECT 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❑
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
a PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED AS REQUIRED BY ANGELES OUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR. THAT THE LEGAL NER OF THE ABOVE
DESCRIBED RESIDENTI ERTY. ,1 BACKFILL SEPTICCTAS 01
SIGNATURE SEEP.PITE:1S) CESSPOOLS
'OF PERMITTEE
JOHN A.—LAMBIE, COU Y. ENGINEERALIDATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR
M.O. CASH
CK,
[.j SCO 5 0 3 1 n. APR -14 1 0 A TOO