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S&E-689 11-85 APPLICATION FOR PERM-IT., 1
S&E-6 •
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I$POSA L
Depax ent of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
ItAKttl
,FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO OWNER 3
BLOCK , ) TRACT 7 O / MAIL I
ADDRESS
N0. OFON BLDGSLOT f. O
_SIZE OF LOT CITY TEL N
® )// 15'DW
USOF
BUILDINGS e4-1 DISTRICT NOVI OUP MAP `
K P
CONTRACTOR
y
ADDRESS t� 'oof CONNECTION DATA
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CITY TEL NO�.0 4� �O STATION Q DEPTH
MANHOLE REFERENCE
❑ STATE 7 CLOWE5�i
REGISTRATION NO >� �/O y ❑ COUNTY
NO I DESCRIPTIOIT OF WORK FEE TYPE OF CTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB M.L.TO P.L.
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELDP. C. N0.
• EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO L� JOB NO
HOUSE SEWER CONNECTING TO
D
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK,PERMIT N0. ROAD PERMIT.
/ CONNECT ADDITIONAL BLDG OR id STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 (J PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE _
OWNER'SpERMT S 1 00
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 YWER. 14LW
HOUSE SEWER _ i�
SIGNED THIS DAY OF � 19 L ,
M CONNECT ADDITIONAL
OWNER OR tl �,vT / ) n. -1-- /� � 1 �'n/� BUILDING OR WORK - -
OWNERS AGENT AA 9/fin/.�f� YL .a/( o L�/�/ ,I /1 ,,{{�//'1 SEPTIC TANK,SEEP,PIT(S)
ADDRESS �(� J 1.OM A UF_ /•C. AND/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES .AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT-1 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 LEGAL OWNER OF THE ABOVE
WER
DESCRIBED RESIDENT L PROPERTY BACKFILL SEPTIC TANKS❑ /
SIGNATURE SEEP.PIT(S) El CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION-1 ROBERT A WOOD, CHIEF PLBG INSPECTOR
., CK. M 0, CASH -
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LAC o ,- IR -9 4
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