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6g642O LIAPPCATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS O
WILLIAM A. JENSEN. Supt oI Building
LOCALITY
NEAREST
FORPLICANT TO FILL ING CRDSS T. zKi
LEGAL
DESCRIPTION LOTNO. OWNER _
MAIL
BLOCK TRACT ADDRESS
NO. OF B
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
B pISTRICT NO. Ga.0 MAP PROCESSED BY
LDINGS
BPG
CONTRACT R ✓ 4K
ADDRESS CONNECTION DATA
✓✓✓✓ 1111
CITY Np STATION DEPTH61
\
141STATE MANHOLE REF E E 'a
REGISTRATION NO / G� ❑ COUNTY V / ^LOWER
NO. DESCRIPTION OF ORK t— F E TYPE OF CONNECTION LENGTH FROM
HOUSE SEWCO NNECTING TO Y, CURB P.L. M.L.TOP.L.
PUBLIC SEW S ER C $5.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR C..I.P. NO, / JOB NO. V
PIT$qND/OR GRAINFIELD @ $10.00 _
HOOSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRI VATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT WAIVER !Alrll RECORD. INSTR.NO. OA E
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIE LD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANOON HOUSE
SEWER OR DISPOSAL SYSTEM 23.p0 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 5 z o0
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS OATEI INSPECTORS SIGNAYTRE
SIGNED THIS IU'� 3LG�-' }vy�
OWNER OR �NEW'NO.SE SEWER
OWNERS gGEJ T CO NECTADDITIONAL
ADDRESS C�j/ BM'DING OR WORK
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 ❑ oRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DI CONNECT FLOG AN.
RESIDE IN, THE ABOV ESCRIB D RESIDENTIAL P OPERTY. ABANDON HOUSE SEWER ,
SIGNATURE
OF PERMTTTEE. BIACK FILL SEPTIC TANKS ❑ o� 'i �, - _ /'�'J lr
/SEEP.PIT 15) ❑ CESSPOOL (l ✓ I ���,,/
VALIDATION ROBERT A. WOOD
CASH SUPERVISING MECHANICAL ENGINEER
8LQI7s 40Q, AUG 13 1 0 0 7.00- a