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76AS42D APPLICATION FOR PERMIT 1
8&E-B89S
ISION OF BUILDING AND SAFETY SEWER-SEWAGE D i S POSA L .
Department of County Engineer
County of Los Angeles BUiI DING
JOHN A. LAMBIE, COUNTY ENGINEER - ADDRESS
® CASSATT D GRIFFIN. SUPT of BLJILDINr LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWN J
DESCRIPTION LOT NO �T �f/ �!�
MAIL
BLOCK TRACT eADDRESS el - "
.r
rIN O. OF BLDGS CITY TEL. N0.
SIZE OF LOT NOW ON LOT •/
USE OF DISTR CT NO - GROUP MAP
BUILDINGS
C , L�
PG
CONTRACTOR /
I
ADDRESS CONNECTION DATA
�
D STATION DEPTH `a `
CITY TEL. NO. .J�2./o
MANHOLE REFERENCE 4 -
TATE � LOWER
REGISTRATIO11<0 ❑ COUNTY
NO DESCRIPTION'ORK FEE TYPE OFC TION LENGTH FROM J
4HOUSE SEWER CONNECTING TO Y. B P.L M.L. TO P.L.
1 PUBLIC SEWER @ $3 SO
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD7 P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO. IMP NO. /Jo JOB NO.
HOUSE SEWER CONNECTING TO /
PRIVATE DISPOSAL SYSTEM - Q $1 00 TRUNK PERMIT NO. ROAD PERMIT NO �-
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT g t 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH TH EIN KAMED CON- APPROVALS DATE INSPEC SI��l ATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SEWER _ NEW HOUSE SEWER
SIGNED THIS DAY 19 CONNECT ADDITIONAL '
OWNEROR BUILDING OR WORK
OWNERS AGEN SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE TVV I AVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE"IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE-LAWS REGULATING ALTER,REPAIR,SEWER OR F
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY HATI AM PROPERLY_ REGISTERED AND/OR DISCONNECT PLUG AND '
L LENSED AS REOUIR BY LOS ANGELES OUNTY AND ATE F ANN HOUSESEWER
C ORNIA OR THA AM .LEGAL NER E AB
r ENT B PPTIC TANKS❑ CESSPOOLS❑ _
SIG G IT(S)
R � ( {
O R '
JOHN A LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N 0 CASH
W _ '4 A 45'0 '