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16A 042. APPLICATION FOR PERM1
COUNTY OF LOS ANGELES SEWER—S AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS C oW o
COLEMAN W. JENKINS, SUPT. OF BUILDING -7 -7
LOCALITY /
FOR APPLICANT TO FILL 24 NEAREST
CPOBS ST.
LEGA
DESCRIPTION LOT NO. OWNER
q MAIL
BLOCK TRACT `/ - ADD
NO. OF BLDG �/ /)�/�
SIZE OF LOT NOW ON LOT CITYfr" ' TEL. NO.
USE OF
BUILDINGS ,/T' �C��fIF DISTRICpT NO. aRR/DP MAP PROD6666EO BY
CONTRACTOR i}- It JI /� I - ` _IlK PO JC/
'wy" lJ V {/�/
ADDRESS �` �� 'x ♦♦♦ CONNECTION DATA
T1, / ( STATION DEPTH
STATE G 'T LIC ,I MANHOLE REFERENCEUPPER
LICENSE NO. / CLA95
NO. DESCRIPTION OF WORK FEETYPE OF ION LENGT FROM /
HOUSE SEWER CONNECTING TO /Y(7 Y. CURB P.L. M.L.T P.L.
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD Q E10.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TOO Y
PRIVATE DISPOSAL SYSTEM $3.00 THUNK PERMIT NO. ROAD PERMIT NO.
O
CONNECT
To
OLDG.OR AFFE�CIOPONO. '3 DA E
WORK TOHOUSE SEWER Q 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELyy/)
U
O
ERTN..CESSPOOL.OgYW ELL.MANHOLE® 86.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING w
SEWER OR DISPOSAL SYSTEM ® 83.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL APPD_
y
Z
WASTE APPROVAL
CHARGES
OWNER r MIS s 2 00
CONNECTION CHARGE FEE
ALITHORIZA ON OTAL FEE —
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. AT IN SP Oq'S BI GNATURE
SIGNED THISD Y O —� 19
OWNER OR NEW HOUSE SEWER /O
OWNERS AGE -
l` CONNECT ADDITIONAL
ADDRESS_ BWLOING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTICTp NK,SEEP,PIT I51
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORVWELL Q
1 HEREBY CERTIFY THAT 1 AM PROP EGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICEN6ED A3 REQUIRE BY LOB ANG ES COU Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWN AND INTEND TO
PESIOE M, THE A DESCRIBED RES PRyP TY. DI6CONNEC PLUG AND
Gj BANOO OUBESEWEP
SIGNATURE ❑
OF PERMIT, KFILL SEPTIC TANKS
SEEP.PIT 161 ❑ CESSPOOLS
AATION JACK R. ALLEN
K. M.G. cwSH SUPERVISING MECHANICAL ENGINEER
4 7 5 3- RAY 1 1 J D 13.0 0,;,
A
CECEBUB 2�,D • .� 71' APPLICATION FOR PERMIT ,
82/
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING `L
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN HE
REsr
(PRINT OR TYPE ONLY)
CP.Ss ST,,eV
EGAL
'
DESCRIPTION LOT NO. OWNER //—
/V r
�J "^ MAIL /J
BLOCK TFACT /S� ADDRESS �YYIFL,
NO. OF BLDG., E
SIZE OF LOT NOW ON LOT CITY TEL. NO. -g—; wO
USE OF
BUILDINGS 1 DISTRICT NO. GROUP CLA55 MAP PROLE SSEp BT
BUIj f
BK
CONTRACTOR �(,��`� ��` Q�!✓ � � � C `^y/_
ADDRESS CONNECTION DATA
CITY O}E TEL. NO. J%> STATION DEPTH
STATE ,y .p ,[/ LIC UPPER
LICENSE NO. "l�llp vV•� OLASS / MANHOLE REFERENCE
OWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 23.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ STOOD CO. IMP, NO. JOB NO,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. }
PRIVATE DISPOSAL SYSTEM ® S3.00 d
CONNECT ADDITIONAL fy� pFFID4VIT AI A[[M[ RECOflD. IN3TR.N0. D4TE O
WORK TO HOUSE SEWER S3.00 V (l V
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE a 55,00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR$T.WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT 1 V
PERMIT NO.
a
INDUSTRIAL V1)
WASTE APPROVAL L
OWNSR�s CHARGES
Y[M J PERMIT s z /orov --)/ rClr� �H
AUTHORIZATION rorAa Pee [/// CONNECTION CXARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE /i ��� / Ifr,/{
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING T/l. / �K
TO THE PUBLIC .EWER. APPROVALS DATE INSPECTOR'S SIENA TUBE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
4DpFE55
BUILDING OR WORK
HEREBY ACKNOWLEDGE THAT SEPT
HAVE REND THIS APPLICATION /IC TANK,SEEP.FT(S)
OR DRAINFIELD
AND STATE THAT THE ABOVE Is CORRECT AND AGREE COMPLY AND
WITH ALL COUNTY OR}IINA NCE3 AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER. REPAIR.SEWER OR
LICENSED As REQUIRED SY.LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE AB VE/\'DESCRIBED RESIDENTIAL PROPERTY. ABANDON ROUSE.EWER
SIGNATV RE /�� BACKFILL SEPTIC TANK5 ❑
OF PERMETTEE ��
BEEP.PIT I51 ❑ CESSPOOLS
VALIDATION,-1 JACK R. ALLEN
cK. M.O, ( AS SUPERVISING MECHANICAL ENGINEER
1AP- 0522n 1-14A7271 '3 D 5.00• N