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76A 6420 – CE808— 9/73 APPLICATION F'OR�/1'sitRMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY.DIVISION BUILDI B
LOCALITY'
NEAREST
FOESCRIPTION
OR APPLICANT TO FILL IN cRoas
T.
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LOT NO. OWNER -Y:��' w 1..— MAIL TRACT ADDRESS °��,.�.�,r,tNO. OF SLOGS.
'," , NOW ON LOT. CITY TEL. NO._ DISTRICT NO. GROUP MAP PROCESSED BY
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GONTRACTOIR-:�•/, K,:.'.r..,. r
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ADDRESS i x,,! .;;rye•'r -a✓ 3'�w.�' CONNECTION DATA
`.� ..'t L. � ,+' o,y !� STATION DEPTH •,.•{
CITY :c'p I .. ., ..
STA E y"' r LI �^ ".� MANHOLE REFERENCE UPP[R
L ICENSEJ Vn
N'O, DESCRIPTION OFy WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER'CONNECTING TO Y. CURB 'PfL. M.L.TO P.L.
PUBLIC SEWER @ $7.00 .r ;;,.+� ! P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO,
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TOd
TRUNK PERMIT NO, ROAD PERMIT NO. t,.a,
PRIVATE DISPOSAL SYSTEM 59.00
CD
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1v[[ [As[r[Mi RECORD.INSTR,NO. D TE V
WORK TO HOUSE SEWER ® $3.00
W
OVERFLOW SEEPAGE PIT.DRAINFIELD J_
EXTN_CESSPOOL.DRYWE LL. $5.00 HWY.OR ST.WIDENING N..
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
MANHOLE 0 $7.00 PERMIT NO. ..,... �"
INDUSTRIAL
O
WASTE APPROVA4"' !y',,Y,
ARQEB LLI
OWNS PERMIT $ 3 00
ER
AUTHORIZATION TOTAL FEE J CONNECTION AOE FIA'
I HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TOA RTO Co THE ABOVE DESCRIBED EXISTING DWELLING
THEPUBLIC SEWER. APPROVALS
DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF —19—
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL i
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
IH
EAEBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 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 Cl ORYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
I
CALFCRN IA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RES DE IN, THE ABOVE DESCRIBED RESAbENTIAL PfIOPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL TIC TANKS ❑
OF PEAMTiTE& - .,. ..ary. SEEP, IT
(S)SEP❑ CESSPOOLS
VALIDATION CK. M.0. CASH
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