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76AAPPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRES s
COLEMAN W. JENKINS,Sup't. of Building
LOCALITY
NEARES
FDFN
OR APPLICANT TO FILL IN CROSS
L b
OF
LOT NO. � � OWNER
MAIL
TRACT ADDRESS
NO. OF BLDG S.
LOT NOW ON LOT CITY TEL. NO. '�" ,d
DISTRICT NO. GROU MAP PROCESSE BY
S /^/�n{� PGTOR ' �� F W J� CONNECTION DATA,, NO. / TATION� DEPTH
C taG�t ^ v
LICE•�,'r-��y� , LICENSE ' / UPPER
N0. ' 7 LASS MANHOLE REFERENCE
NO DESCRIPTION OF WORK FEE TYPE OF CONNIE TIO LENGTH FROM
HOUSE SEWER CONNECTING TO /,S.yj Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $ 5.00 o -
PTI�, SEEPAGE PIT OR RC.NO.
CO.IMP. NO. JOB NO. I'
PITS AND/OR DRAINFIELD C $I 0.00
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR,NO. DATE
WORK TO HOUSE SEWER C 0
$ 3.00 O
REPAIR OR ABANDON HOUSE l�
SEWER OR DISPOSAL SVSTF.M C $ 3.00 !(LJd
HWY.OR ST.WIDENING CL
EXTN.,CESS PO O L, MANI+OLE @ $ 5.00 STATE ENCROACHMENT h
PERCOLATION TEST @ $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
.1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECT R'S SIGNATURE
SIGNED THIS DA _` 19_ 6
OWNER OR � NEW HOUSE SEWER
OWNERS AGENT' S CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
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 1 AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REQUIRED BY ANGLES COUNTY STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT H LEGAL OWN OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB Sc BED ES ID IAL ROP RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE EP.PIT(S) ❑ CESSPOOLS
VALIDATIO r
CK. M.O. CASH
_ LF o995a- iUG 4 1 0 D 7.00