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CESOB 36 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL LI
DEPARTMENT OF COUNTY ENGINEER y7
BUILDING AND SAFETY DIVISION AO gEss p 7i
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING
Locpurr SlJ's2 4�r-/c�
NEAREST
FOR APPLICANT TO FU.L IN ERGS$ $T. 71ulSc /1��'�
OESCRGPTION LOT NO. OWNER \ Y•��
MAIL BLOCK TRACT AOORESS
NO. OF SLOGS.
/D r TEL. NO.
SIZE OF LOT NOW ON LOT CITY
USE OF
BUILDINGS •.�a E �— C DISTRIOT NO. GROUP MAP pgOCEBBEO BY
yy�� BKS
corvTRAcroR Yy- /�/_EI
ADDRESS� 6— -Te 1 C!� UX�l'`Y C ECTION D A
CITY Y C TEL.'NO. �/LJ STATION �1 DEPTH 7� /
STATE LIC MANHOLE REFERENC L� J GUP•
LICENSE NO. GLASS �(�"/ / ER
NO. .DESCRIPTION OF WORK FEE "PE OF CO NNECTIO N LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M. TO p.L. a
PUBLIC SEWER SS.00
SEPTIC TANK.SEEPAGE PIT OR C ® O
PITS ANO/OR DRAINFIELD @ SIO.00 CO. IMP.
HOUSE SEWER CONNECTING TO TRUNK'PE T O. ROAD PERMIT NO. C
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL SLOG.OR AFFIDAVIT I WAIVER EASEREMT RECORD.INSTR,NO. GATE H
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT.DNAINF I ELD W
"TN,CESSPOOL,DRYWELL,MANHOLE@ 55.00
/ AIATER, REPAIR OR ABANDON HOUSE MWY.OR ST.WIDENING
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LSEWER OR DISPOSAL SYSTEM @ 53,00 14262 STATE ENCROACHMENT
PERMIT NO,
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INDUSTRIAL
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WASTE APPROVAL
CHARGES
OWNERS PERMIT 5 z 00
AUTHORIZATION
AUTHORIZATION TOTAL FEE 100 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESC BED EXISTING DWELLING
TO THE PUBLIC S WWE ._ APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS ` AY OF �r V_ ,9
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(5)
1 HEREBY ACKNOWLEDGE THAT HAVE R AO THIS APP KATION AND/OR ORAINFIELO
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ OHl WELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REG TERE AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUN AN STATE OF SEWAGE O ISP.EAl SYSTEM
CALIFORNIA OR THAT A E AL OWNER INTENO TO DISCONNECT PLUG PND
RESIDE IN, THE ABOV R RE T L PA ERTY. ABANDON HOUSE SEWER /p
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMTTTEE El
SEEP.PIT I51 CESSPOOLS
VALIDATION JACK R. ALLEN
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M.0 CASH SUPERVISING MECHANICAL ENGINEER
.
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