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CEBO6
78A642D APPLICATION FO P I4
COUNTY OF LOS ANGELES SEWED—SEWA
GE,
, DISOL• . �-
DEPARTMENT OF COUNTY ENGINEER -
BUILDING
BUMDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County En near
WILLIAM& JENSEN, Supt of Building LOCALITY
NEAREST - `
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNE -
DESCRIPTION LOT NO.
BLOCK. TRACT MAIL '
ADDRESS
NO OF BLDGS. ,
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF � ISTRICT NO. GROUP MAP PROCE ED BY
BUILDINGS
CONTRACTOR B� / G%�WIJ�
ADDRESS Y CONNECTION DATA
CITY �� 0. 40
STATION DEPTH
ATE MANHOLE REFERENCEPPER
+. REGISTRATION N0. U N T YNO. DESCRIPTION OF WORK FEE
r HOUSE SEWER CONNECTING TO _
PUBLIC SEWER @ 3 TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. R P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $ 0
OVERFLOW SEEPAGE PIT, DRAINFIELD -
EXTN CESSPOOL DRYWELL @ $111—
P.C.NO.
HOUSE SEWER CONNECTING TO CO IMP NO. JOB N0. y�
PRIVATE DISPOSAL SYSTEM @ S 0 l�
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ 0 C
SEWEROR DISP SAL SYSTEM HOUSE @ $ 0 STATE ENCROACHMENT a
T PERMIT NO 0
+ INDUSTRIAL
WASTE APPROVAL W
e / CHARGES
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
' AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
OF
y_ _
SIGNED THIS — ly= NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AG T - BUILDING OR WORK r
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION _ _ -- t
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. t SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED AS REQUIRED LOS ANGELES CO STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGAL 0 R OF E ABOVE
DESCRIBED RESIDENT PRO ERTY. BACKFILL SEPTIC TANKS ❑ /'� �{ _�
SIGNATURE SEEP.PITS C1 CESSPOOLS �/ L1
OF PERMITTEE? /1rK j P�_1) V
V
OF ROBERT A. WOOD
OALMATION
Y.0. CASH SUPERVISING MECHANICAL ENGINEER
L F`C a o 'iAy 18 1 P 0 10._ 0
., .
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