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7GA642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONDING
JOHN A. LAMBIE, County EngineerESS
WILLIAM A. JENSENt
of Building
LITY
EST
FOR APPLICAI;9.OAOIN'L S ST.
LEGAL
DESCRIPTION LOT NO. R
BLOCK TRACT ADDRESS
41 NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF - D
BUILDINGS PG
NO. GR MAP PROCESSED BY
r� �4K PG
CONTRACTOR / ---
ADDRESS l7® ci� 9 -/ CONNECTION DATA
CITY TEL. NO
STATION DEPTH
El STATE UPPER/
REGISTRATION NO. IV , �/ ❑ COUNTY-I MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
CL
PUBLIC SEWER @ $5.00 O
P.C.NO. 0
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM @ $3.00 }�
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIV rns EM ENT RECORD. INSTR.NO. DATE W
I WORK TO HOUSE SEWER @ $3.00CL
V
OVERFLOW SEEPAGE PIT,DRAINFIELD to
H WY.OR ST.WIDENING
EXTN.,CESSPOOL,DRYW ELL.MAN H OLE @ $5.00 b
ALTER,'REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.00 _ STATE ENCROACHMENT
PERMIT NO.
tFREIMBURSEMENT
NDUSTRIAL
TE APP OV
OVNER'S PERMIT $ 2 00 G
Q b ONNECT N CHAR FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR ' NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL -
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
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. I
CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL P OPE RTY. ABANDON HOUSE SEWER
SIGNATURE � e
OF PERMITTEE L /i�r BACKFILL SEPTIC TANKS ❑
SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK. (� •'�