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8A642
COUNTY OF LOS ANGELES SEWER-SEWAGE ®9SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
_ LOCALITY �
am NEAREST
FOR APPLI ANT TO FIIoL IN
tSS STLEGALDESCRIPTION LOT N ER D 5 el
BLOCK TRACT MAIL /
ADDRESS // >�
NO.OF BLDGS. t
SIZE OF LOTNOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCES BY
BK P6
CONTRACTOR ✓ / _
ADDRESS JAI
Aj CONNECTION DA A
CITY vP EL.N0. _ _�� STATION DEPTH
r` +� STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. Lj COUNTY . LOWER
NO. DESCRIPTION OF _WORK FEE
' PUBLIC SEWER CONNECTING TO @ $3.00 ~�
TYPE FNNECTI LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR T. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD d
EXTN. CESSPOOL DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. �-'
WORK TO HOUSE SEWER $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT O
SEWER 0 DISPOSAL SYSTEM
@ $1.00 PERMIT NO. CJ
LU
INDUSTRIAL a
WASTE APPROVAL N
CHARGES z
OwNERrS PmuT $ 1 2 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE &V REIMBURSEMENT FEE
MED CON-
TRACTOR TO CHAVE AT IONNECT THE ABOS DATE A ACTDESCRIBED EXISTING_AYI'fh THE HEREIN ADWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THI Y OF 9- NEW HOUSE SEWER r
OWNER OR CONNECT ADDITIONAL
OWNERSAGE BUILDING OR WORK
A DRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HE BY 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 REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEIJ
I HEREBY CERTIFY THAT I A ROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY ANGELES C TY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEG ER OF THE ABOVE
DESCRIBED RESIDEN OPE BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PITS ❑ CESSPOOLS
OF PERMI
AIMATION ROBERT A. WOOD
CK. U.0. CASH SUPERVISING MECHANICAL ENGINEER