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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL dFJS
Department of County Engineer
County of Los Angeles BUILDING
1—�—/
' JOHN A. LAMBIE;, COUNTY,ENGINEER ADDRESS�
® CASSATT D.'GRIFFIN, SUPT OF BUILDING LOCALITY L
FOR APPLICANT TO FILL IN CROSS ST,
DESCRIPTION LOT_ N0,50�(��fJY,C�/D. Q� ( ®V OWNER
/ MAIL
BLOCK TRACT ADDRESS
{��,/ NO. OF BLDGS. CITY TEL. NO.
SIZE OF LOT A 1® O NOW ON LOT
USE OF
'. BUILDINGS ,/vy �� DISTRICT NO. GROUP _ BK MAP PG
°. CONTRACTOR •��
ADDRESS �. / g � 5 �� CONNJECTION DATA d
STATION DEPTH
CITY TEL. NO. 0 ����•� MANHOLE REFERENCE
q ❑ STATE L
. REGISTRATION N0. l d� � ❑ COUNTY a
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING R ,l TYPE OF TION LENGTH FROM
PUBLIC SEWER @ $3.50 •`v Y. CURB/ P.L. M.L. TO P.L.
�O
SEPTIC TANK,SEEPAGE PIT OR -
.PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDP. C. NO. ,
EXTN.,CESS POOL,DRYWELL,MAN HOLE.@ $2.00 CO. IMP. NO. 1.33 o JOB NO.
HOUSE SEWER CONNECTING TO
.PRIVATE DISPOSAL SYSTEM @.$1.00 TRUNK PERMIT N0. ROAD PERMIT N0, eoC.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL '
CHARGES
b CONNECTION CHARGE FEE ..
OWNER'S PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE ._
I HAVE AT THIS DATE-A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS- DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR �" IA� BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PITS) '
ADDRESS AND/OR DRAINFIELD
a
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 i ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE.COUNTY ENGINEER VALIDATIOROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK. M.0.