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CF-808111-87 APPLICATION FOR PERMIT '
CF-808
COUNTY-OF LOS ANGELES SEWER=SEWAGE DISROSAL-
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING' .0
JOHN A. LAMBIE, County En '••Engineer ADDRESS
CASSAIT D. GnLrM, Supt of Building LOCALITYNEAREST
t: '
FOR APPLICANT TO FILL IN CROSS ST.,LEGAL
DESCRIPTION LOT N0. J OWNER ' --MAIL
BLOCK T.ACT.0eLZ74. ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.-NO..
USE OF
BUILDINGS - ' �12 DISTRICT NO. GROUP� •J - MAP
�+ {
CONTRALTO � � � � BK 1 �G
ADDRESS CONNECTION DATA'
CITY -f 7 / TEL.N0. STATION It DEPTH
Ly STATE MANHOLE REFERENCE
REGISTRATION NO. D / COUNTY - LOWER
NO. DESCRIPTION OF WORK F
HOUSE SEWER CONNECTING TO
PUBLIC SEWER TYPE P.
LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. URB P.L. M NGT P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. -
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR �
WORK TO HOUSE SEWER Q $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE �+
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
Ovi=ls PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORMTION I TOTAL FEE O d REIMBURSEMENT FEE
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISDATE-A CONTRACT WITH THEINNGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE T
TO THE PUBLIC SnEWER• _ _ _ ._T _ ._ .•-.__- _ _ _ _ _ ___ ._
SIGNED THItT &La
ryDAY,-1_ 1-Q.
NEW HOUSE SEWER
OWNER OR 1.17/_ - -CONNECT ADDITIONAL"
OWNERS AGENUILDING OR WORK
ADDRESS - - SEPTIC TANK,SEEP,-PIT(S) - -" -- --_ _
AND/OR DRAINFIELD ..
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION • '
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS R ULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
'
I HEREBY CERTIFY THAT' AM ROP IW REG ERED AND/OR SEWAGE-DISPOSAL SYSTEM-•• - ---- - - -- -•• --- -- - --
LICENSED AS REQUIRED OS ANGE OU AND STATE F DISCONNECT PLUG AND
CALIFORNIA OR THAT- M_THE . ER THE YE. ABANDON HOUSE SEWER_
DESCRIBED. IDENTI ROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE _ �f"J - SEEP. PIT(S) ❑ CESSPOOLS _
OF PERMIT
wa
OF ALIDATI -ROBERT A. WOOD -^—
CK. M.0. SUPERVISING MECHANICAL ENGINEER'
- �t�+ o4209�S' MAR 3() 1 0 A 5.00