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7GA64 - APPLICATION FOR PERM-IT
TBA
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
- - DEPARTMENT OF COUNTY ENGINEER "
BUILDING AND SAFETY DIVISION F.��ROR.".'
JOHN-A.'LAMBIE, County Engineer
ADDS 66 -
WILLIAM A. JENSEN, Supt OS Building
FOR APPLICANT_ TO FILL IN
LEGAL s N p Y
DESCfl IPTI ON LOT INC.
. ,. _ - '
BLOCK TRACT '�g 9�
SIZE OF LOT NOW ON LOT CITY T.L. NO.
USE OF
BUILDINGS - DISTRICT NO.1 GROUP MAP- PROCESSED BY
BK �J/
CONTRACTOR /PG
A((DDR ss - „1/. yFi ))C^OONNECTION,DATA
C't TEL. NO Aj Gf a ��O�j�f STATION ^Y C / DEPTH rl
�{�y a ATE MANHOLE REFERENC✓✓E L
REGISTRATION NO. / d// ❑ COUNTY .� ,�C' LOWER
NO. DESCRIPTION OF WORK -FEE TYPE OF CONNECTION LENGTH FROM a
HOUSESEWER CONNECTING TO TY. GURB .L. M.L.T.P.L. O
PUBLIC SEWER C E5.00 ' G P G NO V
SEPTIC TANKSEEPAGE PIT OR JOB NO.
,PITS ANDIOR GRAINFIELD Q SI000 CO.IMP. NO, Ix
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROA.PERMIT NO. O
PRIVATE GISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT I WAIVERASEME RECORD,INSTR.NO. DATE
WORK TO HOUSE SEWER @ E3.00
OVERFLOW SEEPAGE PIGRAINFIELD h
EXTN..0 ESSPOO L.DRYT,W ELL.MANHOLE 0 $5.00
ALTER,REPAIR OR ABANDON HOUSE HWT.OR.ST,WIDENING
SEWER OR DISPOSAL SYSTEM a 5300 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S1 z 00 CHARGES
f- 1
AUTHORIZATION TOTAL FEE FIG CONNECTION CHARGE FEE
11 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWED APPROVALS DATE INSPEC R'SSIGNATURE
SIGNED THIS DAY OF 1�
,OWNER OR A NEW HOU SE SEW ER
!.W
WNEN.AGE NT
CONNECT ADDITIONAL
�A DORE55 / - j / BUILDING OR WORK '
F / / SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ TMS APPLIC ON AND/..DRAT NFIELD
SAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
"I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOU IRE. BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
'CALIFORNIA OR THAT 1%AM THE LEGAL OWNER OF, AND INTEND TO DI5CONNECT PLUG AN.
'RESIDE IN. THE ABOYE DESC IHED RESIDENT IP}O PROPERTY, ABANDON HOUSE SEWER
SIGNATURE /�/Ie
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ /
SEEP.PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT WOOD
I
crc. M... GASH ) SUPERVISING MECHAA NICAL ENGINEER
9 2 8 9t AUG26 1 D 7.0(D 4