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CE808-S-DB APPLICATION FOR PERMIT ,
- 1
EB08- '
COUNTY OF LOS ANGELES - 'SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �Z!
IOHN A. I.AMBIE, County Fmgiaeai ADDRESS
CASSATP D. GRIFFIN. Supt of Building - LOCALITY a
'NEAREST
FOR APPLICANT TOTILL FILL IN ceoss ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT / MAIL
ADDRESS
NO.OF BLDGS. a -
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP ROCESSED BY
BK
�
CONTRACTOR � ,
ADDRESS , CONNECTION DATA
CITY (j,� TEL. N0. STATIONDEPTH
STATE
REGISTRATION NO. MANHOLE REFERENCE UPPE
NO. DESCRIPTION O WORK FEE towER
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. el
EXTOVENFCESSPOOL,DRYWE,LL,MANHOLE Q 2.00 4
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM Q $1.00 CO.IMP.NO. I JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER,
REPAIR OR ABANDON OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
SEWER
'PERMIT N0.
INDUSTRIAL
_WASTE APPROVAL '
CHARGES
OWNERIS -PEST f 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 6--t REIMBURSEMENT FEE gyp_
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 SEWER. ' . / r S�/ ` 4
SIGNED THIS SAY OF I g _NEW HOUSE SEWER 1°,Y�,
COECT
OWNER OR BUILDING ORDWORKAL
OWNERS AGENT
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AN /OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAIM HAVE READ THIS A PLICATI
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
I 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 T 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDJZ�4 PROP TY. BACKFILL SEPTIC'TANKS ❑
SEEP. PITS CESSPOOLS
SIGNATURE 2-
-
OF PERMITTEE
Z
®� VALIDATIC ROBERT WOOD
K.
9.0. CASH SUPERVISING MECHAA NICAL-ENGINEER
' At n-7 02 4� NOV 51 0 A - 5.0 0 �.