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76AS42APPLICATION FOR PERMIT .
1
6A9420 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
IGRN A. LAMIE, Coualy EaqQ�laper
WILLIAM A. IENSEN. Bap'I o1 BWII&SE OCALITY I
FOR APPLICANT TO FILL. IN
CROSS ST.
LEGAL ` Cd,I
DESCRIPTION LOT NO. / µ I OWNER +
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS. -
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO.I GROUP MAP PR ESSED BY
BK PG
CONTRACTOR Y /
AD CONNECTION DATA
CI .ND. f STATION DEPTH
/ ATE MANHOLE REF R E UPPER
REGISTRATION N0. / COUNTY LOWER
NO, DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO 7z L
PUBLIC SEWER @ $ .00 TYPE OF CONI.CTION LEI TN FROM
SEPTIC TANK.SEEPAGE PIT OR Y. P.L. M TO P4-
OVERFLOW
PITS AND/OR DRAINFIELD @ $ .00
EXTNFLCESSPOOLGDRYWELLAINFIEID @ S1.00
HOUSE SEWER CONNECTING TO P.C.NO
PRIVATE DISPOSAL SYSTEM @ 8 .00 CO.IM N JOB NO. �.
a
CONNECT AD0I TI
WORK TO HOUSONAL BC 00
LDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. V
E SEWER .
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ I.OU PERMIT NO. O
M
INDUSTRIAL V
WASTE APPROVAL W
CHARGES
OWNER'S PERMIT $ p 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DAT NT WITH THE HE NAMED CON.
TRACTOR TO CON HE
THE ABOVE SCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SE R.
SIGNED THIS DAY. 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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 CD Y ANO STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGA NER F THE ABOVE
DESCRIBED RESIDEN L ROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S1 ❑ CESSPOOLS
OF PERMITTEE
®' VALIDATION ROBERT WOOD
CASHCL M.Q. CASH SUPERVISING MECHANICAL ENGINEER
Iay,1170 �1' A;R161 i✓ A 5 .00