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CES08. APPLICATION FOR PERMIT 1
aeoe-°-ea COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5628 leeo -
JOHN A- LAMBIE, County Engineer ADDRESS
CASSATT D. GRIFFIN, Supt of Building LOCALITY Templety
NEAREST roa W
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 6 OWNER R
DESCRIPTION LOT N0.
BLOCK TRACT 25202 MAIL
ADDRESS 21121 Rica Road
NO. OF BLDGS. —7 C
SIZE OF LOT NOW ON LOT CITY OV1na N0. D / 2
USE OF
BUILDINGS es DISTRICT NO. GROUP RK PG
MAP PROCESSED BY
CONTRACTOR MeDIIS TUCt1On
ADDRESS BleCONNECTION DATA
CITY dwin ark TEL. NO. D 8-3024 STATION Q DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY /L L LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO /I
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB
M.L.
TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL.DRYWELL,MA NHOLE @ $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT ND.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER J"AJ•i^^ :' 1!`'�?�lr..t/
OWNER OR TTTl'c��irt CONNECT ADDITIONAL
OWNERS AGENT NEW Yy BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS NGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM LEG OW IER OF THE BOVE
DESCRIBED RESIDEN/}} P BACKSEEP.FPIT(S)
IT SILL EP❑C CESSPOTANKS OLS❑
SIGNATURE /
OF PERMITTEE
®. ALIDATION ROBERT A.WOOD
CASH SUPERVISING MECHANICAL ENGINEER
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