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78A842D APPLICATIO FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
LDING J
JOHN A. LAMBIE, County Engineer RESS ,3/ IK ko �C
WILLIAM A. JENSEN. Sup't of Building
ALITY
R LIC N T �� 56 5T.
LE
DESCRIPTION L T O. OWNER
MAIL / O /
BLOCK TRACT ADDRESS Q_
NO. OF BLDGS. CITY �� G TEIt�,7- 6 8-3O j
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP• MAP PaCIGE SSED BY
BUILDINGS CQ ` T NO �(BK/,!1 /`PG J\
CO NTRAC / / J (� V /1/ 1 LQ ( C�Z(�,
ADDRESS CONNECTION DATA
CITY C V� TEL. N STATION DEPTH
/} TATE MANHOLE REFERENCE UPPER
REGISTRATION NO. �/ 2 ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OFC TION r LENGTH FROM
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TO P.L. U
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD,INSTR,NO. DATE
WORK TO HOUSE SEWER @ $3.00 •..s
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE
HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
r
AUTHORIZATION TOTAL FEE P CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. ,�I APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS�AY OFLam—/ i(%_t3r�
OWNER OR !!J _ NEW HOUSE SEWER "
OWNERS AGENT .f7illL.tiG�`
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)'
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND S ATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT ECHE LEGAL OWNER OF, AND I END TO DISCONNECT PLUG AND
RESIDE IN. THE Al DYSC RI BED RESIDE/NTTJi�i PR Y. ABANDON HOUSE SEWER
SIGNATURE _e
/ iL BACKFILL SEPTIC TANKS '
OF PERMITTEE _
SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
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