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` .6D APPLICATION' FOR PERM,'
76A642D A
'78A642
COUNTY OF LOS ANGELES SEWER—SEWAGE, DISPOSAL .
DEPARTMENT OF COUNTY ENGINEER e
BUILDING AND SAFETY DMSION BUILDING C /,
ADDRESS /C K
rOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST- /7
FOR APPLICANT TO IN CROSS ST. C9�
LEGAL OWNER i-
DESCRIPTION LOT NO 4- J
BLOCK TRACT tij 'ADDRESS' -
NO OF BLDGS. - "
SIZE OF LOT NOW ON LOT CITY TEL NO -
USE OF
DI DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS I
BK PG
CONTRACTOR �V �r c, � /
ADDRESS w S�, !T1;1 CONNECTION ATA
CITY a 1/Jn TEL.NO. S ' '(� .ST 1 N ..f. S DEPTH f �
/ STATE MANHOLE REFERENCE PPER
REGISTRATION N0. (D D� `f S � 8 COUNTY J` �, LOWER,
NO DESCRIPTION OF WORK FEE b
HOUSE SEWER CONNECTING TO 3 (gip
PUBLIC SEWER Co) $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC PITS AND/OR TANK,
RAEPAGE INFIELDT OR @ $3 00 r Y. CURB P.L. M.L.TO P.L. -
OVERFLOW SEEPAGE PIT DRAINFIELD '
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO .C.N0.
P
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP.NO. �.�(i-'SCJ JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. O
WORK TO HOUSE SEWER @ $1 00 U ,
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO. p
INDUSTRIAL
-WASTE APPROYAL PpWi
CHARGES V1
OWNER'S PERMIT 2 0000 CONNECTION CHARGE'FEE 4
AUTHORIZATIONJ TOTAL FEE OD 1 REIMBURSEMENT FEE
IHAVE AT S DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CIONNECT THE A OVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO"THE PUBLIC SEWER.
SIGNED THIS 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL '
OWNERS AGENT BUILDING OR WORK - -
ADDRESS - 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,❑ DRYWELL ❑ _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR _
PLUMBING AND SEWERS. - SEWAGE DISPOSAEWER EM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND `
LICENSED.AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGHOUSE AND - -
CALIFORNIA OR THAT I AM THE LEG OW R F THE ABOVE
DESCRIBED REST TIAL PROP E BACKFILL SEPTIC TANKS ❑
SIGNATURE - SEEP PIT, S)
❑ CESSPOOLS. _
OF PERMITTE
Or LIDATION ROBERT A. WOOD
CK
X.O. _ CASH SUPERVISING MECHANICAL ENGINEER _
f� j w �SEP�5 � p Jr �t� �r
C,
p� -.�p24650 IN'SS.EERTS
Y N9VII
CE8088-80 APPLICATION pp�V FO \ E 'T' •{
•,78A6'42D COUNTY OF LOS ANGELES SEWER-SEWAGE -DISPOSAL -DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engfaeer -
WILLIAM A. JENSEN. Supt of Building LOCALITY
NEAREST •.
FOR APPLICANT TO FILL IN CROSS•ST.
LEGAL (TQ � - ,
DESCRIPTION LOT N0. t3 OWNER %
BLOCK - TRACT MAIL
DRESS
+ NO.OFBLDGS. -
SIZE OF LOT NOW ON LOT CITY TEL NO
USE 0 1 *STATEMANH50LE
T N . GRA MAP P CESSED BYBUILDINGS BK PG
CONTRACTORADDRESS �f' CONNECTCITY ��qq TEL.NO. N � DEPTHREGISTRATION NO. 0�� REFERENCLOWER
NO. DESCRI TION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00YPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD (��
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP. NO. / (J JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO. O
WORK TO HOUSE SEWER @ $1 00 U
SEWER OR DISPOSAABANDON L SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT • ca
PERMIT NO O
'INDUSTRIAL U
WASTE APPROVAL
CHARGES to
OWNER'S PERMIT $ 2- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVENAMED CN-
TRACTORgTO CIONNECT THE ABOVE DESCRIBED EXISTIDATE A CONTRACT WITH THEJNG DWELLING 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 SEPTIC TANK,SEEP PIT(S) '
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ElDRYWELL 11
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS - "
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
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 T E AB OV •
DESCRIBED RESIDENTI L P ER . BACKFI,LL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOO S ❑
OF PERMITTE
OF UDATION v ROBERT A. WOOD
m.0. CA6R,
SUPERVISING MECHANICAL ENGINEER_ '
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