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76AG42260 APPLICATION FOR PER IT
6A64SEWER-SEWAGE, DISPOSAL 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIN
ADDRESS r '
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN caoss ST.
LEGAL
DESCRIPTION LOT NO '— OWNER
MA L
BLOCK TRACT < ADDRESS _
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL N0.
USE
BUILDDINGS DISTRICT N0. GROUBK P6 P MAP PROCESSED BY
CONTRACTO
ADORES �� - CONNECTION DATA
CITY L.NO. �dy STATION � ) DEPTH
/ �}��fI/STATE MANHOLE REFERENCE
REGISTRATION N0: �! �F COUNTY /4 LOWER
NO DESCRIPT 0 OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 00 TYPE OF CON ECTI N //LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. P.L. M.L.TO,P.
PITS AND/OR DRAINFIELD @ $ 00
OVERFLOW SEEPAGE PIT DRAINFIELD I
EXTN CESSPOOL DRYWELL @ $ 00 i6,z
HOUSE SEWER CONNECTING TO15 P.C N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 (J c0 IM NO JOB NO. >4
Ck
( CONNECT ADDITIONAL BLDG OR TRUNK PERMI N0. ROAD PERMIT NO. U
WORK TO HOUSE SEWER @ $1 DO
SEWER OR DISPOSAL SYSTEM ALTER REPAIR OR ABANDON HOUSE @ $ OO STATE ENCROACHMENT 07
PERMIT NO O
F
INDUSTRIAL U
_,WASTE APPROVAL W
CHARGES
OVIMR'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 42 14m- 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 SIGNATURE
TO THE PUBLIC SEWER. �.� /�`
SIGNED-THIS AY OF 19_ NEW HOUSE SEWER g 1», /is7/�JyZ,
OW GENT -� BUILDING ORNECT DWORKAL /(>�
ADDRESS SEPTIC TANK,SEEP PIT(S) J
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ-THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL ❑ "
WITH•.ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS -
ALTER;REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY .REGISTERED AND/OR DISCONNE
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF. CT PLUG AND
CEABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L PROPERTY. BACKSEEP.-PIT(S)SEPTIC
❑ CESSPOOLS
/Y�SI'���.r ► , _ ✓ �� a.
SIGNATURE -OF PERMITTE
OF VALIDATIOW ) ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
LACO3 2 3 2AUG 20 1 0 0 10.00-
�����✓
76A 642D - CEBOS - 9/73 APPLICATI�OR PMIT
COUNTY OF LOS ANGELES SEWER—SEW E DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS ,
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CRD66 sr.
LEGAL
DESCRIPTION LOT NO. _166- OWNER / l
�i
BLOCK TRACT �Lj / MAIL MAILADDRESS
NO. OF BLDGS. TEL. NO.
SIZE OF LOT NOW ON LOT CITU
UOF
BUILDINGS DISTRICT NO. GROUP I MAP SEED BY
CONTRACTOR L, -Av�o/6 � � / f`_K-/ Pk �
ADDRESS CONNECTION DATA
CITY STATE //_TEL. NO. q� STATION DEPTH
LICENSE NO �P GLASS !r- MANHOLE REFERENCE 112- - `•/4 le LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y., CURB P.L. M.L.TO P.L. LI-
PUBLIC SEWER ! $7.00
P.C.NO.
SEPTIC TANKSEEPAGE PIT OR
PITS AND/OR DRAINFIELD 41 $10.00 CO.IMP.NO, fI� JOB NO.
.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR �) AFFIDAVIT wAlv[■ 1411N[MT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 Q(/
OVERFLOW SEEPAGE PIT.DRAINFIELD O
EXT N.,CESSPOOL.ORYWE LL. $5.00 V
ArMRlMMiRER ABANDON HOUSE
HWY.OR ST.WIDENING
6iWBR'OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT CJ
MANHOLEPERMITN 0. C~.7
Q $7.00 LLA
INDUSTRIAL
WASTE APPROVAL fn
CHARGES Z
OWNERS PERMIT $ 3 00
AUTHORIZATION TOTAL FEE /6)) CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED OS GLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCPNIA OR THA H GAL OW ER F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A V p D REST NTI L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS Cl
Bill OF PEfIMTTTE SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION CK. M.O. SH
- /o f (-7—
6
0 21'kJUL 23 1 U 0 y.,.i lJ irac