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COUNTY OF LOS ANGELES SEWER—S /AGE DISPOSAL �J
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS o �J
LOCAL
ITY
.�-
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. w
LEGAL Jl �;
DESCRIPTION LOT NO. OWNER
MAIL t
BLOCK TRACT ADDRESS -
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP P
BK PG MACESSED BY
BUILDINGS •P
CONTRACTOR `jt,f -� T + !. d
ADDRESS g-"7_/ A.,* C. CONNECTION DATA
CITY W'A TEL. NO. 7p,c STATION DEPTH
r
STATE 0LIC /y MANHOLE REFERENCE UPPER
LICENSE NO:; , � j CLASS
No. _DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO /'J Y. CURB CP�/ M.L.TO P.L.
PUBLIC SEWER @ $7.00 P.C.NO.
•
SEPTIC'TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO. C 76-/
PITS AND/OR DRAINFIELD C $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. CL
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER 'EASEMENT RECORD. INSTR.NO. DATE u
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD O
EXTN..CESSPOOL.DRYWELL. - @ $5.00 HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE 0
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE @ $7.00 PERMIT NO. a
INDUSTRIAL
N
WASTE APPROVAL
OWNERS PERAIIIT $ 3 CHARGES
f CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
IHAVE 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
ALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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 ❑
I HEREBY CERTIFY THAT 1 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, ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL TY ABANDON HOUSE SEWER
SIGNATURE �> - /�� -,r B/��; BACKFILL SEPTIC TANKS
[I ❑
OF PERM}TTEE ! �✓ ❑
SEEP,PITIS) CESSPOOLS
VALID..
ATIOiVp*
CK. M.O. CASH'
1
6,�0 P.)t 28 1 0 9 1 S.0 0 a