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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
DepcQtment of County Engineer y
County-of Los Angeles BUILDING "c
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 7
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY C� -
a u'
C
FOR APPLICANT TO FILL IN � CROSS ST.
LEGAL jl ..� /V U OWNER
9 DESCRIPTION -LOT N0.
MAIL
v BLOCK TRACT C� ADDRESS '( '
NO.OF 9LDGS.
• CITY TEL. NO.
SIZE OF LOT a NOW ON LOTT
USE OF f y DISTRICT NO. GROUP MAP
BUILDINGS �. ?� 5,,/ BK PG
CONTRACTOR
Y ADDRESS > �. CONNECTION DATA
STATION DEPTH ,
CITY - TEL. NO, �(�
MANHOLE REFERENCE..
.�' STATE a LOWER
REGISTRATION N0. �. . ❑ COUNTY .
NO. DESCRIPTION OF W RK FEE
°.
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROMY.
CURB P.L. M.L.TO P.L.
PUBLIC SEWER_ @ $3.50 -
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD a $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD - / P. C. N0.
EXT N„CESSPO0L,DRYWELL,MANH0LE Q $2,00 - CO. IMP. NO. / s `�e "JOB NO.
HOUSE SEWER CONNECTING TO - ��� � A
0
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
'CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER (D $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE - INDUSTRIAL. -SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S . PERMIT $ 1 Do
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS'DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE, INSPECTORS SIGNATU RE•
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY F 19s CONNECT ADDITIONAL
OWNER-. OR BUILDING OR WORK' '
OWNERSENT' _ SEPTIC TANK,SEEP,PIT(S)
ADDRESS ”' AND/OR DRAINFIELD -
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 ,l ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. R' SEWAGE DISPOSAL SYSTEM '
I .HEREBY CERTIFY THAT L AM. PROPERLY REG_LSTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COU AND STATE OF 'fl ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE L OW R OF THE OVE
+•• DESCRIBED RESIDENT PROPERTY. BACKFILL S
SEEP.-PIT-(,S-), C 1---3-,77 r
SIGNATURE
OF PERMITTE -
JOHN A. LAMBIE. CO Y ENGINEERTION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CASH
. 3 7 7 5- DEC 3.1 4. 4.5 0 �