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76A6421)
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 5
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESSG �f' '
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY {"
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER (J. r
BLOCK TRACT MAIL j �,- w f.�• �j ,,
ADDRESS tR
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS - DISTRICT NO. GROUP MAP PROCESSED BY
na � I BK PG,
CONTRACTOR� � ' GM /'�:. ._,. �
ADDRESS CONNECTION DATA
CITY �,,...., {- TEL. NO.,i�_, e,e_l�,r,.' STATION DEPTH
STATE MANHOLE REFERENCE -f . `
REGISTRATION NO. ® COUNTY t1YPER
f -
NO. DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
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 NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
aK1 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
OWNER'S PERMIT $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 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 DAY OF 19_ NEW HOUSE SEWER
OWNER '9T CONNECT ADDITIONAL
OWNERS AGENT '"• �f, 4:-.'`` -"� BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I 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 DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 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 THE ABOVE
DESCRIBED RESIDE IAA. PROPERTY. BACKFILL SEPTIC TANKS E:1SIGNATURE -4 ` ,. Y SEEP. PIT(S) ❑ CESSPOOLS [:1OF PERMITTEE
®n VALIDATION ROBERT A.WOOD
CK. t!.0. CASH SUPERVISING MECHANICAL ENGINEER