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BA64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION .ILD'NO
/
JOHN A. LAMBIE. County Engineer ADDRESS
WILLIAM A. JENSEN. Supt of Building
LocnuTv �-
NEAREST
FOR APPLICANT TO FILL IN `ROBS ST.
GAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
SI2E OF LOT
/ NOW ON LOTS I CITY TEL. NO.
USE OF
DINGS
BUILDIDISTRICT NO. GROUP MAP PROCESSED BY
ED
CONTRACTOR Q. 1/V/ .y" y( fYJ �I f ��� / �jK e�
ADDRESS y'y � q _"� CONNECTION DATA/
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CIT r TIEL. O.4 C1 Q— STATION y^ DEPTH 6
REGISTRATION NO. �/l tel' J COUNTY MANHOLE REFERENCE /D ' Y•/
NO. GE5CRI PTION OF WORK FEE TYPE OF CONNECTION LENGT FROM
PUBLIC I EWEq CO NNECTING TO ® 55.00 G4 CURB P.L. M.L.TO P.L.
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. -3 �� O
PITS AND/OR DRAINFIELO ® SIO.00
CO.IMP.NO. !OB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® $3.00 �yK
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVII 4SIOIN RECORD.INSTR.NO. DATE G
WORK TO HOUSE SEWER ® f3,00
OVERFLOW SEEPAGE PIT.DRAINF1ELO W
EFTN.,CESSPOOL.DRYWELL.MANHOLE® $5.00 d
ALTER,flEPA1R OR ABANDON HOUSE HWY.OR ST.WIDENING y
SEW ER OR DISPOSAL SYSTEM ® f3.00 STATE ENC R OACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS I PERMIT $ 21 o0 CHARGES
AUTHORIZATION I TOTAL FEE 1 2Ick� CONNECTION CHARGE FEE
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE ^ INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1 19_ - -
OWNER OR to 1� NEW HOUSE SEWER •'G "j y. I '�j• ���
OWNERS AGENT 'y VVV Y��� r
CONNECADDITIONAL
BUILD IN G OROR C
WORK
ADDRESS
SEPTIC TANK.SEEP.PIT 151
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/Oft DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl ORYW ELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPER LY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE
SEEP.PIT IBI ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK. M.O. CASH SUPERVISINGGMECHANICAL ENGINEER
u. j�"0. 2 7'2;3 JW 19 1 O D 7.00- 1