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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING - 7�e
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUP T OF BUILDING
LOCALITYFOR APPLICANT TO FILL IN CROLEGAL DESCRIPTION LOT NO 3 OWNER Q ,V Gf S
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BLOCK TRACT y `�' O ADDRESS S Q Ae
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OT NOW ON LOT CITY �Io TEL. NO y 6
DISTRICT NO GROUP MAP PROCESSED BY
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y /(p `l { CONN.,EICTION DATA
.[ a� TEL NO O 7 STATION / �S�DEPTH /
STATE LI ^/ MANHOLE REFERENCE (v UPPER
LICENSE NO D CLASS
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FRO
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER 0 $5 00 Q
P C NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/
OR
0 51000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ $300 Q
/ CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlv[Y EAS eY[MI RECORD INSTR NO DATE U
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD Q
EXTN CESSPOOL DRYWELL MANHOLE
$S 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING W
SEWER OR DISPOSAL SYSTEM ® $300 STATE ENCROACHMENT a'
PERMIT NO N
hu Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $ z 00 CHARGES
AUTHORIZATION TOTAL FEE D 00 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TQ 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 �� D
OWNERS AGENT,
CONNEEA
IONAL
BUILDIORK
ADDRESS
SEPTICEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND�OFIELD '
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY "
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ` CESSPOORYWELL ❑I HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND�OR ALTER SEWER OR
LICENSED AS REQUIREDBYLOS ANGLES COUNTY AND STATE OF SEWAGSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER•OF, AND INTEND TO DISCONLUG AND
RESIDE IN THE ABOV/EE DESCRIBED ESIDENTIAL PROPERTY ABANDE SEWER
SIGNATURE ///./
OF PERMTTTEEv II�� BACKFILL SEPTIC
VALIDATION JACK R. ALLEN
CK M Q nsH SUPERVISING MECHANICAL ENGINEER
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