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CE808 01B-B3
6A64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENTOFCOUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADo
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST �' PY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL Y✓ � ,SO C
DESCRIPTION LOT NO. OWNER
MAIL Ss�e.
BLOCK TRACT 1 ADORES'
NO. OF BLDGS.
S12E OF LOT Xl NOW ON LOT... CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NO, GROUP MAP PROCESSED BY
BK PG
CONTRACTOR (�n,�r O
ADDRESS YY ,�yL CONNNECTION DATA
CITY Q TEL. NO. STATION DEPTH
❑ STATE UPPER
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TIP FC_ONNECT ON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. R P.L. M.L.TO P.L.
PUBLIC SEWER $5,00 EL
Y A
SEPTIC TANK.SEEPAGE PIT OR /i ��/ 9019'f
NO O
PIT'AND/OR GRAINFIELD f10.00 I CO.IMP. O. J" B NO. / U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM I@ 33.00 ^
CONNECT ADDITIONAL BLDG.OR /1 AFFIDAVIT AIY SEXEX V0
RECORD.INST . NO. DATE
WORK TO HOUSE SEWER ® 33.00 U
OVERFLOW SEEPAGE PIT,DRAINF IELDI•
E%TN.CESSPOOL.DRYWELL.MANHOLE $5.00
. .
ALTER.REPAIR OR ABANDON HOUSE HWYOR STWIDENING N�1
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCgOACHMENT L
PERMIT NO.
INDUSTRIAL
WASTE APP AL
CHARGES
OWNERS PERMIT C 4 z 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
-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 SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S) A
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION pAD/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REDUIRED 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 ABOVE DEBCRJBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEW ER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITTEE_��.( - /
SEEP.PITIS) 1CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. ..0. CASH
Lh�� 2.S.6 .5 G AUG 2 0 1 O D 5.0 0