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CESO ZISPLICATION FOR PERM
78A842D COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BuiLDING
ADDRESS
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPT LOT NO OWNER
BLOCK TRACT MAIL ��`` - ,. � p
ADDRESS T —(%VY
'�+ NO OF BLDGS.
SIZE OF LOT �/1 NOW ON L0T CITY TEL NO
USE OF
BUILDING .21 DISTRICT NO BK PG GROUP MAP PROCES BY
�O
CONTRALTO j 1Q/
ADDRESS ! CONNECTION DATA
CITY TEL.N0. - v `STATION• DEPTH .
STATE 'MANHOLE REFERENCE /I
REGISTRATION NO COUNTY LOWER
No. DESCRIPTION OF WORKFEE
HOUSE SEWER CONNECTING TOh
PUBLIC SEWER @ $3 00 d/ TYPE OF CONNECTION LENGTH FROM
PEPTIC TS AND/ORDRATANK,SEEINFGELDPAE PIT OR @ $3 00 Y CURB P L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00
HOUSE SEWER CONNECTING TOP.C NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. N0. JOB NO. y,
CONNECT ADDITIONAL BLDG ORT N0. ROAD PERMIT N0. " V
WORK TO HOUSE SEWER @ $1 00
SEWALTER REPAIR
SYSTEM HOUSE @ $1 00 STATE'ENCROACHMENT RI
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL W
CHARGES w
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT WITH THE I�NGAMED DWELLI'NG APPROVALS ' DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. ,
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _BUILDING OR WORK.
ADDRESS - 1 SEPTIC TANK,SEEP.PIT(S)
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 11
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR _
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1HEREBY CERTIFY THAT 1' AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER '
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN PROPERT BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS _
OF PERMITTE
OF VALMATIOJ� ROBERT A. WOOD
cK, M.o. CAsa SUPERVISING MECHANICAL. ENGINEER
�:�IZ
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