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`6A643-64 APPLICATION FOR PERMI 4/, .,
76A642D COUNTY OF LOS ANGELESDEPARTMENT OF COUNTY ENGINEERSEWER— EWAGE D
BUILDING AND SAFETY DIVISION BUILDING y �� p
JOHN A. LAMBIE, County Engineer ADDREss V` (� (�!
WILLIAM A. JENSEN, Supt of Building
LOCALITY
CROSSSST.
FOR APPLICANT TO FILL IN
LEGAL I
DESCRIPTION LOT NO OWNER •MAILBLOCK TRACT ADDRESS NOOFBLDGSSIZE OF LOT NOW ON LOT CITY ,� (�'(,71I TEL NO.�$�fUSE OFDISTRICT NO. GROUP MAP PROCESS
BUILDINGS
BK PG
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CO NT RACT OR� � y �`f•' ✓`r 1/
ADDRESS . 4 0 /' CONNECTION DATA
�'(r'j •(�` TEL. NO �{• Fj / STATION I r DEPTH
CITY O I
STATE
REGISTRATION NO. I y/�f 0 1 '2— COUNTY MANHOLE REFERENCE » r LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENG H FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO. IMP. NO. 3 JOB NO. a,
PITS AND/OR DRAINFIELD $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVITw�IVtll [At[M[NT RECORD,INSTR.NO. DATE LK
WORK TO HOUSE SEWER $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5,00 V
EPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING UJ
EWER OR DISPOSAL SYSTEM G $3.00 7 00 STATE ENCROACHMENT h
PERMIT NO, Z
INDUSTRIAL ._
WASTE APPROVAL
OWNER'S PERMIT $ z o0 CHARGED
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE O
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 SEW /� APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS�DA OF '/�./e c- 16 . , ,
OWNER OR - NEW HOUSE SEWER - -
OWNERS AGENT � �` 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 15 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,13k'p�J.R,SEWER OR Z
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE POSAL SYSTEM
'CALIFORNIA OR THAT M THE LEGAL WNER AN IN NO TO DISCONNECT PLUG AND
RESIDE IN, THE AS VE ESCRIB D R ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PITS) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
CK. M G cASH SUPERVISING MECHANICAL ENGINEER
i tL� 2 G 0 3`o DLC 4 10 D 5.00N }'
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