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6A64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADORES.
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ROE5 ST.
EGAL f
[A..
SCF IPTI ON LOT NO. /J OWNER
MAIL _
OCK TRACT Lys/ (Q O� AOO RES.
NO, OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
E OF t DISTRICT NO. GROU MAP PROCESSED BY
ILDINGS
NTRACTOR /r
RESS CONNEY • TEL. NO. f 6 a STATION DEPTH
�/ (RESTATE MA N HOLE REF E R EN CE UPPER
REGISTRATION NO. a ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB R.L. M.L.TO P.L. T
PUBLIC SEW ER ® 55.00
P.C.NO. d
SEPTIC TANK.SEEPAGE PIT OR O
PITS gN0/OR ORgINFIELD 510.00 CO.IMP.NO. JOB NO.
V
TOV BE SEWER CONNECTI NO TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLBG.� /j AFFIOAV wAlv[R A[[n[ RECORD.INSTR.N GATE O
TO HOUSE SEWER @ 53.00 Gv V [
OVERFLOW SEEPAGE PIT.DRAINFIELD ��V' �� U
E%TN..CESSPOOL,DRYWELL.MANHOLE� 35.00 W
ALTER. HOU.E N
B HWY,OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACH T Z
PERMIT NO
A' INDUSTRIAL
WASTE APPROVAL
CHARGES
WNER'S - PEAMIT sI 21 o0
AUTHORIZATION CONNECTION CHARGE FEE TOTAL FEE D
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT PEE
TRACTOR TO IS
THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT /
ADDRESS CONNECT ADDITIONAL /.7_Y Y
BUILDING OR WORK (�
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑ '
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
CE
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE OISPO GAL SYSTEM L
CALIFORNIA OR THAT I AM THE LEGALOWNEROF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE E DESCRIBED R 'D EN ABANDON HOUSE SEWER
TI yL PROpEft ❑
/Iy// /LJ/('`,('/{^-f//
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TgNNS
SEEP,PIT(5) ❑ CESSPOOLS ❑
OVALIDATION ROBERT A. WOOD
CK.
M.0, CASH SUPERVISING MECHANICAL ENGINEER
C