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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 BUILDIN7_ F_,VM
/0 C
JOHN A, L IE, County Engineer ADDRES
WILLIAM A. JENSEN, Supt of Building LOCALI >Y
NEAREST
FOR APPLICANT TO FELL IN CROSS ST. C/
LEGAL `� OWNER
DESCRIPTION LOT N0, v
BLOCK TRACT 2 MAIL
ADDRESS /7 ?I-t14
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY > TEL. NO T 2
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCES ED BY
l BK P6
CONTRACTOR _14 0 G
ADDRESS CONNECTI DATA
CITY j TEL.NO. ) 3�� STATION 3 DEPTH
�7 STATE MANHOLE REFERENCE , UP
REGISTRATION NO. J �— COUNTY i
No DESCRIPTION OF _WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 OCA
TYPE OF CONNECTI LENGTH FROM �
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ 58.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ 52.00 2
HOUSE SEWER CONNECTING TO PSC.N0. J O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. Im
ALTER,REPAIR
DASPOR OSAL ABANDON HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL LY
WASTE APPROVAL d
N
CHARGES Z
Ovi7mls PERNIIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT-THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATIJRE
TO THE PUBLIC SEW
SIGNED THISSk DA) — NEW HOUSE SEWER
OWNER OR 1r� CONNECT ADDITIONAL `
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
THEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM- PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI P OPERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S) CESSPOOLS rl
OF PERMITTEE
ALIDATION ROBERT A. WOOD
td r.o. CASH SUPERVISING MECHANICAL ENGINEER
L&71590 MJ17 5.00 M