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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS U /�
COLEMAN 1S'. .IIi;NKINS,Supt. of Building -T
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. "� �� OWNER J/7
MAIL
BLOCK TRACT ADDRESS
NO. oTr BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USELD INGS U//-4 e /� DISTRICT NO. GROUP MAP PROCESSED BY
IBUI '/ BK PG _
CONTRACTOR y® Iq C /
C.
ADDRESS 3 0 _ CONNECTION DATA
CITY r TEL. NO. STATION DEPTH
LICENO. NSE / �/ `/z CLASSLICENSE ry PPER
/(J f.^1 ` MANHOLE REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OFC CT N LENGTH FROM
/ HOUSE SEWER CONNECTING TO ' Y. 'CURB P.L. M.L.TO P.L.
PUBLIC SEWER C' $ 5.00 0- '.
SEPTIC TANK, SEEPAGE PIT OR P.C.NO. A
PITS AND/OR DRAINFIELD C $10.00 CO.IMP.NO. z9JOB NO, O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. ATE O
WORK TO HOUSE SEWER C' $ 3.00 0
R' REPAIR OR ABANDON HOUSE !,� (�
SEWER OR DISPOSAL SYSTEM l- $ 3.00 W
HWY. OR ST.WIDENING a
EXT N.,CESSPOOL, MANHOLE @ N$ 5.00 STATE ENCROACHMENT z
I PERCOLATION TEST CO $ 5.OG PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER / if
OWNERS AGENT /
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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 ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY 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 ABESCRIBED RESIDENTIA OPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE OV BACKFILL SEPTIC TANKS ❑
SEEP,PITS) ❑ CESSPOOLS ❑� ��'�
VALIDATIO
CK. M.O. CASH
LAGO 9 7 7 6 JU` 2 5 1 0
0 7.0 0 N Q