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76A64tl~•/ APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING J O�
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building �� E �y r
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST s;^rL '� E
LEGAL ,Q
DESCRIPTION LOT NO OWNER 10, 41A V//y
BLOCK TRACT 3 MAIL 5.2/J
� ADDRESS �(J��/�/9 fl(
/` NO OF BLDGS n /
SIZE OF LOT 60 ?C 11 NOW ON LOT CITY TP
H - � (H
- JT A7
TEL .NO � lj � �
USE OF �FS '
BUILDINGS C DISTRICT NO GROUP MAP PROCESSED BY
+ r . —.
BK PG
CONTRACTOR O�.L�/v "
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO - DESCRIPTION OF WORK FEE - TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P.L >-
PUBLIC SEWER @ $5,00 d
SEPTIC TANK,SEEPAGE PIT OR PC NO O
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL INISMISM'8 AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NOI DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT -
PERMIT NO
INDUSTRIAL �-/-
WASTE APPROVAL VS
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION I 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
OWNERS AGENT CONNECT ADDITIONAL ^
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PITS)
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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSEDAS 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 AB VE� DESCRIBED RESIDEN?lAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE / � � BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
LACa 5 4 4 1 NOV 2 1 0 D 5.0 Q