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C5808 6-60 ,APPLICATION FOR PERMIT
76A642N - COUNTY OF LOS ANGELES .SEWER-SEWAGE DISPO AL 1�
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING --
ADDRESS
IONN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt ni Building LOCALITY
NEAREST
FOR APPLICAN TO FILL IN CROSS ST.
66 �/
LEGAL OWNER �_tlh Nv
DESCRIPTION LOT N0.
BLOCK TRACTMAIL ppmm
Q ADDRESSI vp I-
NO.OFSLDGS. --]� r '
SIZE OF LOT NOW ONLOT vv L• kz"CZ- CITY L. NO.
USE OFBUILDINGS , �J"(�:..��4+1 DISTRICT NO. GRO MAP PROCE11 SS BY
n BK P
CONTRACTOR 4' R" � - / 1
ADDRESS ••••••/// CONNECTION AT
CITY 4 TEL.NO./_.�.��L✓N STATION , DEPTH
a J / e �] STATE MANHOLE REFERENCE 9
N0. I J % / S lJ COUNTY LVZ-5—
REGISTRATION O L E
NO, DESCRIPTION OF WORK FEE r -
' HOUSE SEWER CONNECTING TO I
PUBLIC SEWER @ $3.00 TYPE 0 TION LENGTH FROM
PITS ANO/OR DRAINFIELD SEPTIC ANK-7-SEEPAGE T OR @ $3.00 Y. CURB F.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN-.. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO - P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO. r
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. ' p
WORK TO HOUSE SEWER @ $1.00 l3 V
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. 0
IND U STRIAL U
WASTE APPROVAL W
CHARGES
PWNER'S//WPER $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE .
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- '
TRACTOR TO CONNECT THE ROVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE.PUBLIC S WER �,,y(p� /J
SIGNED THI$ U YOF_b'' LOJi u'1. NEW HOUSE SEWER
OWNER OR �Y IGL CONNECT ADDITIONAL
OWNERS AGENY P BUILDINGORWORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
IHEREBY. ACKNOWLEDGE THAT 1 -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 COUNTY AND STATE.OF. ABANDON HOUSE SEWER
CALIFORNIA OR TH T 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED REST DEN A PROPERTY. BACKFILL SEPTIC TANKS [I.SEEP. PIT(S ❑ CESSPOOLS.
SIGNATURE
OF PERMITTE -
®" - VALIDATION ROBERT A, WOOD
CK N.O.. CASH SUPERVISING MECHANICAL ENGINEER
11 AQG 7 n p p 6iUU D
B?THt
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