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COUNTY OF LOS ANGELES SEWER—SEWAGE DOSPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BuILDING ~
ADDRESS- `
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
-- •...,.,.... - NEAREST
FOR APPLICANT L TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO., •S - ` OWNER '
BLOCK. - TRACTMAIL
ADDRESS
N0.• F BLDGS.
SIZE OF LOT NOW OK LOT CITY " -TEL. NO.
�,. USE OF •,�. ._.a, - � .:. ry
BUILDINGS - DISTRICT NO.1GROUP
/ (� I MAP PG 27CL;/
BY
BK
�
ADDRESS - CONNECTION DATA
CITY_ TEL.N0. STATION K"f '� DEPTH - -
/ STATE MANHOLE REFERENCE UpPE
REGISTRATIO NO. ❑ COUNTY .LOWER ?
No. . DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER- @ $3.00 TYPE OF G¢AFN-ECTION LENGTH FROM 7 lD
SEPTIC TANK,SEEPAGE PIT OR Y. CURB� � P.L. M.L.TO P.L.
C/
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
3 - HOUSE SEWER CONNECTING TO JP C.NO.
PRIVATE DISPOSAL SYSTEM @ S1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.ORTRUNK PERMIT NO. ROAD PERMIT NO.L
WORK TO HOUSE SEWER $1.00
� ,�
@
ALTER, REPAIR ORABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @.$1.00 PERMIT NO. -
INDUSTRIAL
- WASTE APPROVAL - -
CHARGES
5
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
` AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT.T ABOVE DESCRIBED EXISTING DWELLING APPROVALS DA E INSPECTOR'SSIGNATURE
TO THE PUBLIC S%ER
SIGNED THISDyAY7 OF 19 NEW HOUSE SEWER 1 fes/
OWNER CONNECT ADDITIONAL
OWNERSAGENT
AGENT- BUILDING OR WORK -
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ;. CESSPOOL ❑ DRYWELL ❑WITH ALL COUNTY ORDINANCES -AND STATE LAWS .REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF AgpNDON HOUSE SEWER
' CALIFORNIA OR. THAT AM THE LEGAL OWNER OF THE ABOVE .411
DESCRIBED RESIDEN I ROPER BACKFILL SEPTIC TANKS ❑_ r" y SP1 '
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
y-
OF PERMITTEE >OF VALIDATION ROBERT A. WOOD
CK.
N.0. CASH SUPERVISING MECHAN.ICAL,.ENGINEER -
J