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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D O S POSH L
Department of County Engineer.
County of Los Angeles BUILDINGRES
AD
ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER ,' t
® CASSATT D GRIFFIN,'SUP'T OF BUILDING LOCALITY T'0— Y K l U L� Cy -
FOR APPLICANT TO FILL IN NEAREST
LEGAL ,'� - - - OWNER
DESCRIPTION LOT NO.
f o �. JE / MAR
BLOCK TRACT
ADDRESS
�• SIZE-OF-LOTS-5- NOW NO^ OF BLON LOTT - CITY �w TEL. NO.A7'
,
USE OF, DISTRICT NO. GROUP MAP
BUILDINGS
CONTRACTOR / I BK 47
J
< CONNECTION DATA
'r ADDRESS ff
'/ •�• STATION `� . DEPTH /
CITY EL. NO.
MANHOLE REFERENCE U
— ❑ STATE WER
5 REGISTRATION NO. - ❑ COUNTY
No. DESCRIPTIO OF WOR FE o TYPE OF ON LENGTH FROM '
HOUSE SEWER CONNECTING TO y- RB• P.L. M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR :x -
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P, C. N0.
e EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 - CO, IMP. NO. �. � .1013 NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 ,f TRUNK PERMIT NO. ROAD PERMIT NO. ,
CONNECT ADDITIONAL BLDG.OR �, STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
I. CHARGES
_ CONNECTION CHARGE FEE
OWNER'S PERMIT S t 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEES'
I HAVE AT THIS DATE A CONTRACT WITH,THE HEREIN NAMED CON- APPROVALS DATE INSPE TOR'SSIGNATU.RE
�? TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, / t NEW HOUSE SEWER
v SIGNED THISDAY OF 1—<64A 19`�
CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK
`. OWNERS AGENT
�J SEPTIC TANK,SEEP, PIT(S)
ADDRESS '" ('- ,/%. AND/OR DRAINFIELD
1 HEREBY•ACKNOWLEDGE THAT I HAYE READf THIS APPLICA ION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND.. STATE LAWS REGULATING s ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM -
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
-
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE DISCONNECT PLUG AND
OF ABANDON HOUSE SEWER -
CALIFORNIA OR THAT 1 THE LEGAL OF THE POVE
DESCRIBED RESIDBACKFILL SEPTIC TANKS❑ �
SIGNATURE / / SEEP. PIT(s) ❑ CESSPOOLS'
OF PERMITTEE
JOHN A. LAMBIE, COON ENGINEER VALIDATION— ROBERT A. WOOD, CHIEF PLEIG. INSPECTOR
CK. N.O.
ACO 53=6 7 a' SEP 3 0 1_ A 4.5 0 0