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CE606.6.66 APPLICATION, FOR PERMIT.
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL • 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING co
ADDRESS
JOHN A, LAMBIE, County Engineer
CASSATP D. GRIFFIN. Supt of Building ' LOCALITY
NEAREST
FOR APPLICANT TO FILL IN crsoss sr.
LEGAL
DESCRIPTION LOT NO. OWNER Jy f./r, '
BLOCK TRACT / MAIL '
4 ADDRESS
'NO.OF BLDGS.
SIZE OF LOT NOW ON LO CITY TEL.N0.
USE OF d"
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR' ^
ADDRESS DATA
CONNECTION DATA
CITY TEL.NO. STATION DEPTH
STATE
;L4,2 MANHOLE REFERENCE
REGISTRATION NO. / COUNTYLOWER
No.. DESCRIPTION OF WOR FEE' del
HOUSE SEWER CONNECTING TO `
PUBLIC SEWER Q $8.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OFC TION LENGTH FROM
Y. UR P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $8.00 - _
OVERFLOW SEEPAGE PIT, DRAINFIELD `
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 "
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 - CO.IMP.NO. 'JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER 1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
- WASTE APPROVAL
CHARGES
OWIEWS PERNIIT $ 21 00 CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DA F 19— NEW HOUSE SEWER / ) h/•
OWNER OR i CONNECT ADDITIONAL /
OWNERS AGE BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 01-1 C/
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ I/�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROP Y RE STERED AND/ R DISCONNECT PLUG AND
LICENSED AS REQUIRED B LOS AN S OU AND STAT OF ABANDON HOUSE SEWER /
CALIFORNIA OR THAT THE GAL W R F THE OVE
DESCRIBED RESIDEN71 PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PITS CESSPOOLS❑
OF PERMITT
ROBERT A.
OOD
®r 0� SUPERVISING MECHANICAL ENGINEER
_
DC0.4 2 3 - OCT 21 i o A 6.0 0
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