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76A6420-63 APPLICATION FO PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS /� F7/rTr
WILLIAM A. JENSEN, Supt OI Bllilalttg LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL •�/ ✓ � // ,(� �/ /��/✓
DESCRIPTION LOT N t� OWNER. Cl� O{�GGG/// ✓ L
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL .NO.
USE O F ��4///�
IF
DISTRICT NO GROUP MAP
BUILDPROCESSED BY
--- BK PG
CONTRACTOR �• . �:j�7/ 9CJfyJ�p• �/'
ADDRESS /30• '��%rG Qq/,fJ /��•► CONNECTION I5ATA -
CITY //� //7Qp�ei TEL NO. 7 0/ STATION7 DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY �L�� be�LiGi�
NO DESCRIPTION OF WORK FEE TYPE OF C CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y RB P L M L TO P.L.
PUBLIC SEWER @ Ss 00 QQ P.G.NO. d
SEPTIC TANK,SEEPAGE PIT OR - JOB NO O
PITS AND/OR DRAINFIELD $1000 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® $300 e� I=
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300 V
OVERFLOW SEEPAGE PIT,DRAINFIELD U
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00 d.
OR ST WIDENING
ALTER,REPAIR OR ABANDON HOUSE HWY. N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 2 00
AUTHORIZATION _TOTAL FEE y CONNECTION CHARGE FEE _ 4
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 SE ER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNEROR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.PIT(S)
I HEREBY A KNOWLEDGE TH HAVE REAb THIS APPLICATION AND/OR DRAINFIELD
AND STATE T AT THE ABOVE I CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I 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 THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO D CRIBED R L PROPERTY. ABANDON HOUSE SEWER `
SIGNATURE / J BACKFILL SEPTIC TANKS ❑
OF PERMITTEE LO _
SEEP,PIT(S) ❑ CESSPOOL
VALIDATION ROBERr A. WOOD
SUPERVISING MECHANICAL ENGINEER
d,,
M O CASH
L0o0 9 3 7,:; 2ITR27 0, D
7.00—
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