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S&E-669 11.55 APPLICATION FOR PERMIT 1
S&E-8 '
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles. BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 6 .0
® C[ASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY 0-��e2���� ���
FOR APPLICANT TO FILL IN CROSS s.
DE CRIPTION LOT NO. OWNER 7 ZgE—&���f�J�
MAIL
BLOCK TRACT ADDRESS '
NO. OF BLDGS. CITY TEL. N0.
SIZE OF LOTAIXI NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS LgK
CONTRACTOR � O
ADDRESS /CONNECTION DATA
0 STATION �(�Q.
DEPTH YJ
CITY N0. MANHOLE REFERENCE. _ PP
•OF STATE c LOWER
REGISTRATION NO. d".�.q ❑ COUNTY
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTI LENGTH FROM
HOUSE SEWER CONNECTING TOY. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50 �O
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00 M
OVERFLOW SEEPAGE PIT, DRAINFIELD T �x P. C. N0.
EXTN.,CESSPOOL,DRYWELL,M AN HOLE Q $2.00 CO. IMP. N0. J (J JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL l� A 7 &46U2&d2
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT Q 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
APPROVALS DATE INS ECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWE NEW HOUSE SEWER
SIGNED THISDAY OF 19 CONNECT ADDITIONAL
Q
OWNER- OR BUILDING OR WORK
OWNERS ^GEN SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY A N LEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL El,AND STATE THA HE 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
IICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 THE LEGAL WNER OF THE ABOVE ------
DESCRIBED RESIDENTIA 0 ERTY. .00 71
BACKFILL SEPTIC TANKS❑ 9
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLSD�,f
OF PERMITTEE
mom
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT ASWOOD. CHIEF PLBG. INSPECTOR
CK. N.O. CASH 6
3 0 7 O'D-V OCT r3 4 4.`J 0 0 .