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76A6420 APPLICATION FOR PER IT
76A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS (p sC/
WILLIAM A. JENSEN, Sup't of Building
L OC ALITV
NEAREST
FOR APPLIC T TO FILL I CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF aLe6GS `7
SIZE OF LOT NOW ON LOT CITY TEL .NO.
USE OF DISTRICT NO GR OU MAP ROT
BY
BUILDINGS 73
CT) PIS
/�
CONTRAC R `C
ADDRESS CONNECTION DATA
CITY TEL NO. �! STATION / t DEPTH
UPPER
STATE !
REGISTRATION NO COUNTY MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CON ON ` LENGTH F M /
HOUSE SEWER CONNECTING TO �f Y RB PL M.L TO P.
PUBLIC SEWER @ SS 00
P C.NO.
SEPTIC AND�OR DRAINFIELD @ S10 00 TANK,SEEPAGE PIT OR - JOB NO. O
PITS CO IMP. N
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER CASEMENT RECORD INSTR NO. DATE
WORK TO HOUSE SEWER @ $300 0
OVERFLOW SEEPAGE PIT.DRAINFIELD t)
EXTN,CESSPOOL,DRYWELL,MANHOLE 0 E5,00
ALTER,REPAIR OR ABANDON HOUSE H OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
OWNERS PERMIT 2 00 WASTE APPROVAL
CHARGES
S
AUTHORIZATION TOTAL FEE Q CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SI NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
' HEREBY ACKNOWLEDGE THAT I 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 ❑
IHEREBY 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 DERIBED R IDENTI PROPE RT ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
/,,rLIDATION ROBERT WOOD
eK. M.0 CASH SUPERVISING MECHANICAL ENGINEER
I
APR 4 1 0 -D_ '�:C .0 01