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76A6420 l�dll PUCATMN FOR FIERMT
76A 642D (� tl B�
COUNTY OF LOS ANGELES SEWER-SEWAGE D O SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fADIRESSLDING
`
JOHN A, LAMBIE, County Enqineer
WILLIAM A. JENSEN, Supt of Building CALITY (i
FOCI PIeI AP1T TO S QST. �d✓af"
LEGAL � OWNER
DESCRIPTION LOT N0.
BLOCK TRACT MAIL n
T ADDRESS oG�
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY L. NO
USE OF
BUILDINGS DISTRICT NO. GROUP BK P6 P$
MAP or"USED BYy
C J
CONTACTOR
ADDRESS CONNECTION DATA
CI - TEL N0. �`00f� STATION / DEPTH
fATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION F _ FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER e $ •00 TYPE OF CO TION LENGTH FROM �
SEPTIC TgNK,SEEPAGE PIT OR Y. C PL. MLTO PL. sl
PITS AND/OR DRAINFIELD f .00 P. M.L. P.
OVERFLOW SEEPAGE PIT.DRAINFIELD _ >_
EXTN CESSPOOL DRYWELL @ S .00 O_
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ E100 TRUNK PERMIT N0. ROAD PERMIT NO. 177 7�15
'EWEWOR DISPOSAL SYSTEM HOUSE @ S(00 STATE ENCROACHMENT O
PERMIT NO. U
INDUSTRIAL Lu
If d
WASTE APPROVAL to
CHARGES z
owm'S PERMIT j 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEEAl") REIMBURSEMENT FEE
CT WITH THE HEEIN NED CON.
TRACTOR TO CIONNECT THE DATE ANTR�E DESCRIBED EXIST NGADWELLING APPROVAM DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. '
SIGNED THIS F 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRES SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THA 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
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTE
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS Rin
LOS EL S UNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR A TS
L ER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESTL RO RTY. SEEP.PIT(S) SSPOOLS
SIGNATURE
OF PERMITTEowl I
VALIDATION ROBERT A. WOOD
Os H.0. CASH SU�P,nEgRVISING MECHANICAL ENGINEER
3-6,
76A643-61
APPLICATION FOR PERMT
6A84
COUNTY OF LOS ANGELES SEWER—SEWAGE ®QSP®SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING o
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Suildfng_ LOCALITY
NEAREST
FOR C T T CROSS ST.
LEGAL 3L OWNER
DESCRIPTION LOT N0.
BLOCK TRACT' 'ADDRESS -�
DDRESS
/NO.OF BLDGS. +
SIZE OF LOT NOW ON LOT CITY EL. NO
USE OF - _ -
BUILDINGS DISTRICT NO. GROUP MAP PYQCESSED BY
BK P
CONTRACTOR
ADDRESS // v CONNECTION DATA C `j
- CITY TEL.NO. STATION ! & DEPTH
//•/1 � L/>s ATE MANHOLE REFERENCE
' REGISTRATION N0. �JLG �d Q COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $100 TYPE OF CO N ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR T. P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S i.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ s'..00 - n,
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ S 00 "1CO IMP. NO, i JOB NO. V
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER S 00 - TRUNK PERMIT NO. ROAD PERMIT N0.
'�
ALTER,REPAIR OR ABANDON STATE ENCROACHMENT G
SEWER OR DISPOSAL S TE / @ $
.00 PERMIT NO
INDUSTRIAL CL
WASTE APPROVAL f1
H
CHARGES Z
ROWNEWS PEFMIT $ O CONNECTION CHARGE FEE
i
A�tV aizOMATION TOTAL FEEI
REIMBURSEMENT FEE
t, I HAVE AT THIS DATE A CONTRACT WITH THE NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBENG DWELLING APPROVAM, DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS_,! AY OF19_ NEW HOUSE SEWER
OWNER OR 6/f! CONNECT ADDITIONAL
OWNERS AGENT / BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
IHEREBY ACKNOWLEDGE TH 1 HAVE REAPPLICATIONAND STATE THAT THE ABOVE IS CORRECT AE TO COMPLY CESSPOOL ❑ DRYWELLWITH ALL COUNTY ORDINANCES AND STATREGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWE SEWAGE DISPOSAL SYSTE1 HEREBY CERTIFY T T I AM PROPERLYERED AND/OR DISCONNECT PLUG AND
LICENSED AS RE B LOS ANGELES ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA A LEGAL THE ABOVEDESCRIBED RES ENT] L PROBACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S ❑ CESSPOOLS
OF PERMITTE
ALIDATION ROBERT A. WOOD
21.0. CASH SUPERVISING MECHANICAL ENGINEER
CsR
29 g 1 -0 2 5000-
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