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76A642D APPLICATION FOR PERMIT
76A 642 '
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE. County Engineer ADDRESS (!
WILLIAM A jENSEN, Supt of Building LOCALITYNEAREST
CROSS ST. R'1�7�
FOR APPLICANT TO FILL IN /
LEGAL OWNER ( 1,/L
DESCRIPTION LOT N0.
BLOCK TRACT C„�S HAIL r q L L�
ADDRESS J
NO.OF BLDGS. 7
SIZE OF LOT NOW ON LOT CITY OC ' 7 TEL. G
USE DI DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
0 BK P6"
CONTRACTOR �7 0 L✓�I�
ADDRESS Q : 0,?
CONNECTI N DAT
CITY 7 TEL.N0. Z STATION j DEPTH
STATE MANHOLE REFERENCE PP
REGISTRATION N0. Cv �— COUNTY
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC STIC TEWER @ S3.00 TYPE OF CONNECTIO LENGTH FROM
PITS AND/OR DRAENFGELDT OR @ $
S 00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT.DRAINFIELD >'
EXTN..CESSPOOL.DRYWELL $
2.00 d
HOUSE SEWER CONNECTING TO
P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. N4H.MOr /J V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. �-'
WORK TO HOUSE SEWER 51.00
SEWER. R DISPOSAL SYSTEM HOUSE @ $
1.00 STATE ENCROACHMENT 0
PERMIT NO. u
INDUSTRIAL a
WASTE APPROVAL t)
CHARGES ?
ov;mis PERMIT 5 2 00 CONNECTION CHARGE FEE
TH
AUORIZATION -TOTAL FEE c U REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. LS
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVADATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW�R�
SIGNED THIS—QDAY OR )AA) 19 NEW HOUSE SEWERi:�^�^-
OWNER OR / CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
LNEBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION -
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
LL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPAIR,SEWER OR
G AND SEWERS. SEWAGE DISPOSAL SYSTE
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
NIA OR THA AM THE LEGAL WNER OF THE ABOVE
ED RESIDEN AL ROPERTY. BACKFILL SEPTIC TANKS ❑
RE SEEP.PIT(S CESSPOOLS
MITTE
JVMMATION ROBERT A. WOOD
cK M.G. CASH SUPERVISING MECHANICAL ENGINEER
1 6 2 % JAN 1 -7 1 0 D 5 .00