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76A642D APPLICATIONFOR P RMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE ®ISPOS L
6
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, CouatY Enggi�neer ADDRESS
WILLIAM A. JENSEN, Supt of Budding LOCALITY
NEAREST
FOR APPLICANT TO FIM IN CROSS ST. 04
LEGAL /�
DESCRIPTION LOT N0. i Q OWNER CJlt- Q
BLOCK= TRACT6110-Lm 7_'Or
MAIL
CD ADDRESS
iS
�,/ ,10.OF BLDGS.
SIZE OF LOT O NOW ON LOT CITY TEL. NO F
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCES BY
K PG
CONTRACTOO /
ADORES CONNECTION DATA
CI EL N0. D STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY
NO. 1 DESCRTPTION OF _WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CTION LENGTHROH
SEPTIC TANK,SEEPAGE PIT OR Y. R P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ 33.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2.00 a
HOUSE SEWER CONNECTING TO -imP.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER 9 $1 00
SEWERO EDISPOSAL S STEN HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL LiJ
WASTE APPROVAL CL
Q)
CHARGES Z
OW.RIS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I REIMBURSEMENT FEE
I HAVE AT CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIST NGA CONTRACT WITH THE HEREINAMED DWELLING APPRO` = IDATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. "r"'
SIGNED THIS OF 19_ NEW HOUSE SEWER
CONNECT ADDITIONAL
{� OWNERS AGENT BUILDING OR WORK
ADDRESS— SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 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 SYSTE I
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT
ULUGANDSE i
CALIFORNIA OR TH I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED OR L PROP TY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP PITS ❑ CESSPOOLS P
OF PERM ITTE
VALIDATION ROBERT A.A WOOD
CK. M.0. GASB SUPERVISING MECHANIC:AL'ENOINEER
L�,
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