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76A 842D APPLICATION FOR PER IT
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COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O
JOHN A LAMBIE, County Enggmeer ADDREss
WILLIAM A. JENSEN. Sup't of Bu>ldmg
LOCALITY,,
NEAREST
FOR APPLICANT TO FILL IN
CROSS ST
LEGAL C '
DESCRIPTION LOT NO �,J / OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP MAP ,.PROCESSED BY
BK PG
CONTRACTORlz
ADDRESS CONNECTION DATA
CITY ,� TEL NO /y D G! 5 AT ON14_1 DEPTH
STATE / !!! UPPER
y / 7 (��.I{ MANHOLE REFERENCE _ l r ����
REGISTRATION NO :sL C 3 / .z L� COUNTY I/
NO DESCRIPTION OF WORK FEE TYPE OF CON ECTION LENGTH FROM t
HOUSE SEWER CONNECTING TO Y RB P L M L TO P L O
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR J C NO V
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO OB NO
cz
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N O
PRIVATE DISPOSAL SYSTEM @ $300 3
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 _ a
OVERFLOW SEEPAGE PIT DRAINFIELD Z
EXTN CESSPOOL DRYWELL MANHOLE @ $S 00 HWY OR ST WIDE ANG
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM �_ $3 00 STATE ENC ROgC ENT e
PERMIT
�`✓ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S
AUTHORIZATION TOTAL FEE G /` 1 CONNECTION CHARGE 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 SEW R /� APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF -� %�fl—..9C� 19 �/
/
OWNER OR NEW HOUSE SEWER "'c�
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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 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 ABO/VE DES IBED RESIDENTIAL PERTY ABANDON HOUSE SEWER
SIGNATURE /��� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE (�_ SEEP PITS) ❑ CESSPOOLS ❑
ALMATION ROBERT A WOOD
cK M O CASH SUPERVISING MECHANICAL ENGINEER
bVla5776:� FEB21 11 D 25.00- `t
76A64 10.82 APPLICATION FOR PERMIC
78A842D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOS L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FRE
la
JOHN A LAMBIE. County Enq meet 4v S r
WILLIAM A. JENSEN, Supt of Bu>ldmg FOR APPLICANT TO FILL IN
LEGAL +J� .�/
NJ
DESCRIPTION LOT NO J OWNER
n MAIL
BLOCK ID TRACT `/ ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP I PRO SSED BY
BK PG U
CONTRACTOR C, A. Davis Sewer Contractor /-�
3�
d 1 Il
ADDRESS 1720 W. 139th St. s / CONNECTION DATA
CITY Gardena TEL NO (=A 19060 T TION � DEPTH
REGISTRATION NO ZO 32 El STATE MANHOLE REFERENCE , A UPPER - d
LJ COUNTY -'
NO DESCRIPTION OF WORK FEE TYPE FCAO
O NECTION ,L GTH FROM i O
HOUSE SEWER CONNECTING TO '� "' Y C RB P L M L TO P L ` V
PUBLIC SEWER SS 00
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ SIO 00 CO IMP NO JOB NO / O`Y-,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N
A $300
b W
PRIVATE DISPOSAL SYSTEM S3 00 /% lLLLLLL1JJJJ
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVEII EASEMEIIT RECORD INSTR NO DATE~
WORK TO HOUSE SEWER @ $300 y
OVERFLOW SEEPAGE PIT DRAINFIELD Z
EXTN CESSPOOL DRYWELL MANHOLE @ S5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WID\
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 96 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE i
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN IIAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLICSE R ,/ 101,
APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS :DAY OF ._11� \ i ' /
OWNER OR \ NEW HOUSE SEWER y(I(, p¢.
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATI N
RWOR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL Cl
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 ABBOOJJVE D SCRIBED RE/SIDE NT AL PROPERTY ABANDON HOUSE SEWER
SIGNATURE /�/l��/r BACKFILL SEPTIC TANKS ❑
OF PERMITTEE `- rr/� (i//JJ//�`��`��/ ❑
SEEP PITIS) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
�lLo 5 7 7 5.a FEB 2 1 1 0 D 7.0 0—