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05-E-6E APPLICATION FOR PERMIT 1
EBOB- COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGDRESS 7ea
o
AUILDIN
JOHN A. LAMBIE, County Fmgineez emp TT
CASSATT D. GRIFFIN. Supt of Building LOCALITYFOR APPLICANT TO FILL IN NEAREST/7 CROSS ST. T DESCRIPTION LOT NO. / OWNER JohngeralddBLOCK TRACT MAIL 21OaR (�,ADDRESSNO. OF BLDG$. a ED 2-
SIZE OF LOT NOW ON LOT CITY
USE OFAe$ 111111-
BUILDINGS DISTRICT NO.1 GROUP I MAP P CESSEO BY
CONTRACTOR • • M. ' BK PG
ADDREssFj136 No . Bleeker !a CONNECTION DATA -
CITY baldwin Park TEL. NO.hi) STATION DEPTH
STATE MANHOLE REF RENCE 3 ,-
REGISTRATION NO. COUNTY
No. I DESCRIPTION OF WORK FEE !O LowER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM /
PITS AND/OR DRAINFIELD @ $5.00 Y. CURD P.L. M.I I.TO P.L. J
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO - ',c- 'O-
PRIVATE
C. NO,
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO,
WORK TO HOUSE SEWER @ $1.00
SEWERe E DISPOSAL SYSTEM HOUSE STATE ENCROACHMENT
@ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL '
CHARGES
OWNEWS EAM
PIT S 2 00 CONNECTION.CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECT R's SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
THE PUBLIC SEWER.
SI f `n
SIGNED THIS DAY OF I y_ NEW HOUSE SEWER _/G-fN
OWNER OR CONNECT ADDITIONAL
NE1Y
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK.SEEP,PITS)
ADDRESS— AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENR BACKFILL SEPTIC TANKS[ISIGNATURE SEEP.PITS EI CESSPOOLS FI
OF PERMITTEE QS J ,
®rALiROBERT WOOD
CK. Y..0.o. CASH SUPERVISING MECHANICAL ENGINEER
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